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i^LD  PROBUira  I 


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WORLD  PROBLE 
DISEASE  PREVENTION 


ISSUED  BY 

UNITED  STATES  PUBLIC  HEALTH  SERVICE 
TREASURY  DEPARTMENT, WASHINGTON 


D.C. 


C20 


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TODAY'S  WORLD  PROBLEM  IN  DISEASE 
PREVENTION 

A  NON-TECHNICAL  DISCUSSION  OF  SYPHILIS 
AND  GONORRHEA 


John  H.  Stokes,  A.  B.,  M.  D. 

Chief  of  the  Section  of  Dermatology  and  Syphilology, 
The  Mayo  Clinic,  Rochester,  Minnesota. 

Assistant  Professor  of  Medicine,  Mayo  Foundation  Graduate  School, 
University  of  Minnesota. 

V.  D.  22 


\. 


This  iooJclet  was  tvritten  l)y  Dr.  John  H.  Stokes  as  a  patri- 
otic service  and  was  given  to  the  V.  S.  Public  Health 
Service  for  puilication  and  distrihution  to  those  interested 
in  the  Government's  program  for  Venereal  Disease  Con- 
trol, being  carried  on  in  cooperation  tvith  the  various 
State  Boards  of  Health. 


20 


copy  RIGHT 

JOHN  H.  STOKES 
1919 

(The  United  States  Public  Health  Service  is  autliorized 
to  use  this  book  in  its  venereal  control  work 
without  the  payment  of  royalty.) 


INTRODUCTION. 

The  years  of  the  great  war  have  brought  a  sharp  awakening  of  the  American 
people  to  the  need  for  facing  the  greatest  present-day  problem  of  public  health. 
Almost  over  night  we  seem  to  have  changed  from  a  nation  with  its  eyes  shut 
and  its  ears  stopped  into  a  country  alert,  interested,  and  on  the  road  to  the 
full  accomplishment  of  what  had  hitherto  been  declared  impossible. 

In  endless  repetition  the  advocates  of  the  doctrine  of  laissez  faire  have  told 
us  of  the  antiquity  of  prostitution  and  of  the  certainty  that  it  would  be  with 
us  forever  in  undimmished  prevalence.  They  have  said  likewise  that  syphilis 
and  gonorrhea  and  chancroid — that  group  called  venereal  diseases  because  of 
their  commonest  method  of  transmission — would  never  come  under  public 
health  control,  because  they  were  "secret"  diseases  and  "different  from  other 
diseases."  Therefore,  the  sufferer  must  be  left  undisturbed,  to  spread  disease 
to  others  and  to  decay  in  self-neglect,  unless  chance  information  or  intuition 
made  him  seek  and  appreciate  the  advice  of  a  conscientious  and  skilled  physi- 
cian. 

Under  the  system  of  the  past  the  physician  could  treat  the  patient  as  little 
or  as  much  as  he  saw  fit,  and  be  accountable  to  no  one  for  the  protection  of 
society  against  the  refractory  or  careless  patient.  The  patient,  on  the  other 
hand,  could  stop  his  treatment  and  ignore  precautions  against  the  exposure 
of  others  whenever  the  whim  seized  him.  Up  to  the  time  of  the  war,  the 
American  health  officer,  with  his  brilliant  record  for  conquering  such  lesser 
evils  as  yellow  fever,  typhoid  fever,  smallpox  and  malaria,  felt  that  the 
venereal  diseases  were  entirely  outside  his  field.  He  accepted  the  dictum  that 
they  were  "different."  As  a  result,  venereal  diseases  maintained  their  prev- 
alence and  the  cases  were  not  even  counted.  Society  paid  for  its  neglect  in 
wrecked  homes,  childless  marriages,  invalidism,  blindness  and  insanity.  And 
still  venereal  diseases  were  "different." 

Out  of  the  war,  along  with  all  the  suffering  and  destruction,  has  come  much 
good.  One  benefit  has  been  a  change  of  this  attitude  and  the  creation  of  an 
American  plan  for  banishing  the  vast  amount  of  ill-being  and  pain  and  death 
caused  by  venereal  diseases.  This  American  plan  is  an  entirely  new  concept. 
It  is  not  new  in  any  one  part,  but  new  in  its  combination  of  all  the  consistent, 
worth-while  methods,  and  new  in  that  it  squares  with  the  highest  American 
standards  of  upright  living.  And  it  is  sound  in  its  sociology  as  well  as  in 
its  preventive  and  curative  medicine. 

If  the  American  plan  is  to  live  and  develop  steadily  into  a  better  and  still 
more  effective  plan  of  the  future,  the  people  of  America  must  understand  it. 
The  silence  of  the  leaders  must  bQ  broken  and  their  mouths  must  utter  the 
truth  with  understanding.  The  lawyer  and  the  statesman,  the  teacher  and 
the  clergyman,  need  more  than  the  selected  data  which  are  scattered  about 
with  popular  propaganda.  They  should  have  ready  access  to  those  funda- 
mental facts  about  venereal  disease  on  which  successful  methods  of  control 
must  rest.  To  present  these  facts  Dr.  Stokes  has  prepared  this  book.  To 
make  them  widely  available  the  United  States  Public  Health  Service  has 
published  a  large  edition  and  is  sending  it  out  to  the  teachers  and  leaders  of 
the  people---particularly  the  clergymen  witli  their  wonderful  opportunities  for 
warning,  comforting,  and  advising. 

The  plan  was  born  with  the  war.  Those  high  in  authority  were  prompt  to 
see  the  need  to  forestall  the  debauching  and  disease-breeding  conditions  which 
were  wont  to  arise  in  the  neighborhood  of  camps  and  follow  in  the  trail  of 

3 


armies.  Said  Newton  D.  Baker,  Secretary  of  War,  in  a  letter  of  May  26,  1917, 
to  the  Governors  of  tlie  States  and  the  State  Councils  of  National  Defense : 
"We  cannot  allow  these  young  men,  most  of  whom  will  have  been  drafted  to 
service,  to  be  surrounded  by  a  vicious  and  demoralizing  environment,  nor  can 
we  leave  anything  undone  which  will  protect  them  from  unhealthy  influences 
and  crude  forms  of  temptation.  Not  only  have  we  an  inescapable  responsi- 
bility in  this  matter  to  the  families  and  communities  from  which  these  young 
men  are  selected,  but,  from  the  standpoint  of  our  duty  and  our  determination 
to  create  an  efficient  army,  we  are  bound,  as  a  military  necessity,  to  do  every- 
thing in  our  power  to  promote  the  health  and  conserve  the  vitality  of  the 
men  in  the  training  camps."  Likewise  did  Josephus  Daniels,  Secretary  of 
the  Navy,' speak  unequivocally  on  the  responsibility  of  the  state  and  national 
governments,  for  the  protection  of  the  sailors. 

The  problem  was  attacked  with  vigor.  Commissions  on  Training  Camp 
Activities  were  established  by  the  War  and  Navy  Departments.  They  cooper- 
ated with  the  Surgeons  General  of  the  Army  and  Navy  and  Public  Health 
Service  in  keeping  conditions  wholesome  around  the  camps  and  training  sta- 
tions. Liquor  and  prostitution  were  suppressed  in  wide  zones  around  places 
of  training.  Red-light  districts  were  closed.  Healthful  recreation  was  made 
possible  in  town  and  in  camps.  Athletics,  books,  music,  and  dances  were 
arranged  for.  The  life  of  the  soldier  was  made  as  normal  as  camp  life  and 
rigorous  training  would  allow. 

But  this  was  not  all.  The  soldier  himself  was  taught  the  dangers  of 
venereal  diseases  and  the  advantages  of  a  continent  life,  through  lectures, 
exhibits,  stereopticon  slides,  and  most  vividly  by  motion  pictures. 

The  civilians  living  near  army  camps  and  in  communities  engaged  in  war 
industries  were  bombarded  with  appeals  for  cooperation,  and  they  usually 
gave  it  unstintingly.  Clinics  were  established  and  hospital  beds  provided  for 
the  treatment  of  venereal  diseases,  even  under  quarantine  when  that  was 
necessary  to  protect  the  public  health.  The  United  States  Public  Health 
Service  and  the  Red  Cross  maintained  venereal  disease  clinics  in  extra-canton- 
ment areas  for  the  purpose  of  cutting  down  the  incidence  of  venereal  disease 
by  curing  the  sick,  and  in  this  way  reducing  the  health-hazard  of  the  soldiers. 
For  soldiers  who  had  become  infected,  or  who  had  been  exposed,  prompt  and 
efficient  treatment  was  provided  by  the  army.  Soldiers  in  infectious  stages 
of  venereal  diseases  were  kept  in  camp  as  an  added  protection  to  the  civilian 
community. 

In  these  ways  much  disease  was  prevented,  but  the  draft  army  soon  pro- 
vided some  revealing  figures  that  called  for  different  efforts.  It  was  found 
that  most  of  the  cases  of  venereal  disease  among  our  soldiers  were  contracted 
before  the  men  came  into  camp.  In  fact,  over  five-sixths  of  the  venereal 
disease  treated  in  the  army  in  America  up  to  the  time  of  the  armistice,  was 
acquired  before  the  boys  put  on  the  uniform.  This  evidence  showed  that  the 
environment  of  the  home  town  was  more  dangerous  to  the  health  of  young 
men  of  draft  age  than  the  carefully  guarded  surroundings  of  the  camp. 

And  then  began  the  fight  to  protect  the  soldier  of  anticipated  future  drafts. 
The  campaign  had  to  be  carried  to  all  communities,  whether  or  not  they  were 
near  army  camps.  State  boards  of  health  widened  their  activities.  Congress 
recognized  the  problem  and  created  a  Division  of  Venereal  Diseases  in  the 
Public  Health  Service,  and  also  an  Inter-Departmental  Social  Hygiene  Board 
to  correlate  the  venereal  disease  control  work  of  the  War,  Navy,  and  Treasury 
Departments.  Over  four  million  dollars  were  appropriated  to  carry  out  meas- 
ures for  control  by  the  government  and  to  assist  the  states  in  financing  the 
work  being  initiated  by  their  boards  of  bealth. 


Under  the  leadership  of  the  new  division  of  the  Public  Health  Service, 
further  developments  were  rapid.  Nearly  all  the  states  made  venereal  disease 
reportable,  with  due  precautions  for  secrecy  in  the  interests  of  the  patient. 
There  developed  a  widespread  movement  for  the  establishment  of  clinics  in 
which  the  best  of  treatment  could  be  made  available  to  the  many  who  need 
it  but  cannot  afford  the  high  cost  of  the  prolonged  treatment  necessary  for 
the  cure  of  syphilis  and  chronic  gonorrhea. 

With  all  these  measures  aimed  at  disease  prevention,  there  has  been  arising 
a  feeling  of  sympathy  for  those  who  are  suffering  from  venereal  disease.  A 
deep-rooted  and  unreasoning  antagonism  is  being  replaced  by  understanding 
and  a  desire  to  help.  Social  service  by  trained  workers  is  bringing  to  the 
clinics  people  who  are  diseased,  following  up  those  who  have  dropped  from 
view  before  their  cure  was  completed,  and  offering  hope  of  health  to  the 
infected  families  and  associates.  Experts  in  constructive  institutional  work 
are  taking  up  the  task,  persons  experienced  in  dealing  with  those  who  require 
restraint  and  training  and  encouragement,  as  well  as  medical  care.  And 
throughout  it  all  there  has  been  a  hopeful  optimism  not  often  seen  among 
those  who  deal  so  often  with  the  degenerate  and  the  prostitute. 

The  prevalence  of  venereal  disease  among  soldiers  in  the  United  States 
and  in  the  expeditionary  forces  has  been  very  low,  much  lower  than  had 
been  expected  .on  the  basis  of  the  earlier  experience  of  other  armies  in  the 
conflict.  In  addition  to  the  prevention  of  new  cases  of  venereal  disease,  the 
amount  of  venereal  disease  in  the  army  was  reduced  by  the  treatment  of 
many  thousands  of  men  who  had  contracted  their  disability  in  civil  life  and 
would  have  continued  to  spread  infection  if  released  from  the  army  untreated. 

What  was  done  to  keep  the  soldier  fit  should  be  done  year  in  and  year  out 
for  the  health,  efiiciency,  and  well-being  of  every  young  man  and  young  woman 
of  America.  They  must  be  taught,  guided  and  protected,  not  only  through 
individual  attention,  but  especially  by  the  correction  of  vicious  influences  in 
the  community  and  the  creation  of  an  environment  which  is  wholesome  and 
stimulating  to  better  living.  The  war  has  furnished  a  successful  demonstra- 
tion.   May  its  lessons  not  be  forgotten. 

Under  the  leadership  of  the  Public  Health  Service  the  state  boards  of 
health  are  working  and  planning  for  venereal  disease  control.  People  are 
organizing  in  many  communities  to  resist  any  attempts  of  the  tenderloin 
influence  to  bring  back  the  old  conditions  of  vice  recognized  and  disease 
rampant. 

The  first  duty  of  all  who  wish  to  take  a  hand  in  the  fight  is  to  inform  them- 
selves so  that  they  may  lead  and  help  others  intelligently.  And  this  brings 
me  again  to  the  volume  which  Dr.  Stokes  has  prepared,  not  so  much  for  the 
benefit  of  the  readers  themselves  as  for  the  welfare  of  the  much  larger  body 
which  will  be  influenced  through  their  words,  example,  and  direct  assistance. 

Venereal  diseases  have  at  last  beeen  recognized  as  prevalent,  destructive 
and  preventable.  They  have  been  brought  into  the  open  and  they  cannot 
stand  the  light. 

WILBUR  A.  SAWYER, 

Major,  Medical  Corps,  U.  8.  A. 
Washington,  D.  C. 

April  3,  1919. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Boston  Library  Consortium  IVIember  Libraries 


http://www.archive.org/details/todaysworldproblOOstok 


CONTENTS. 


PAGE 

Introduction 3 

Auhob's    Prefack 13 


PART  I. 
THE  NATURE  OF  THE  GENITAL  INFECTIONS. 
Chapter  I — The  Source  of  the  Genital  Infections. 

The  Genital  Infections  Defined 17 

General  Principles  of  Transmission  of  the  Genital  Infections. .....  18 

Individual  Resistance,  Peculiarities  of  the  Germs 18 

Intimate  Contact  and  Moisture  Necessary 19 

Chapter  II — The  Genital  Sore. 

Antiquated  Distinctions  Between  Syphilitic  and  Chancroidal  Sores.  21 

Modern  Methods  for  Recognizing  Early  Syphilis 21 

Early  Examination  and  No  Previous  Treatment 22 

The  Microscopic  Examination  is  Essential 22 

Reassurance  for  the  Timid 23 

The  True  Chancroid 23 


PART  II. 

GONORRHEA. 

Chapter  I — History,  Cause  and  Prevalence. 

Gonorrhea  a  Localized,  Resistant  Infection 27 

The  History  of  Gonorrhea 27 

The  Gonococcus,  the  Cause  of  Gonorrhea 28 

The  Microscope  Essential  in  the  Treatment  of  Gonorrhea 29 

The  Prevalence  of  Gonorrhea 29 

Gonorrhea  in  Men 30 

Gonorrhea  in  Women 30 

Chapter  II — Gonorrhea  in  Men.     Symptoms,  Tests  for  Infectiousness. 

Acute  and  Chronic  Gonorrheal  Inflainmation .32 

The  Course  of  Acute  Gonorrhea  in  the  Male 33 

Posterior  Gonorrhea  and  the  Genital  Complications 33 

Causes  and  Complications  of  Chronic  or  Persistent  Gonorrhea 33 

Stricture    34 

Relapses  and  Flare-Ups  :  "Gleet"  or  "Morning  Drop" 34 

Chronic  Gonorrhea  of  the  Prostate  and  Urethral  Glands 35 

Tests  for  Chronic  Urethritis,  etc 35 

Morbid  Fear  of  Gonorrhea 36 

Gonorrheal  Nervous  Prostration 36 


V 

Chapter  III — Systemic  Gonokrhea  and  Gonorrhea  in  Women  and 

Children.          .  page 

Reasons  for  the  Greater  Seriousness  of  Gonorrhea  in  Women 37 

Course  of  Gonorrheal  Infection  in  Women 38 

Gonorrhea  and  Pregnancy 38 

Gonorrheal  Child-Bed  Fever  and  Sterility 39 

"Pelvic  Inflammatory  Disease" 39 

Concealed  or  Latent  Gonorrhea  in  Certain  Glands 40 

Systemic   Gonorrhea ;    Rheumatism,   etc 40 

Gonorrhea  of  the  Eye   (Gonorrheal  Ophthalmia) 41 

Prevention  of  Gonorrheal  Blindness 41 

Gonorrheal  Inflammation  of  the  Genitals  in  Girl  Children 42 

Vulvo- Vaginitis  in  Hospitals 42 

Chapter  IV — Treatment  and  Hygiene  of  Gonorrhea. 

The  Difficulties  of  Treatment 44 

Local  and  General  Measures  Employed 44 

The  Patient's  Cooperation -    45 

The  Treatment  of  Chronic  Gonorrhea 45 

The  "Bad  Cold"  Lie,  Fakes,  Drug  Stores  and  Quacks 46 

Treatment  of  Gonorrhea  in  Women 46 

The  Obstinacy  of  Chronic  Gonorrhea  in  Women 47 

The  Abortive  or  Suppressive  Treatment  of  Gonorrhea 48 

Hygiene  of  Gonorrhea 48 

Chapter  V — The  Cure  of  Gonorrhea.     Gonorrhea  and  Marriage. 

Gonorrhea  is  Usually  Curable 50 

The  Carrier  of  Infection  the  Real  Danger 50 

Modern  Tests  for  Determining  Infectiousness  and  Cure 51 

Gonorrheal  Childlessness  in  Men  and  Women 52 

A  Child  Unborn 52 

Gonorrhea  and  the  Medical  Examination  Before  Marriage 53 

Protection  of  the  Fiancee 54 

Protection  of  the  Pregnant  Woman  Against  Gonorrhea 54 

A  Warning  in  Regard  to  Double  Marital  Infection 55 

Remediable  Weaknesses  of  the  Existing  Situation 55 


PART  III. 
SYPHILIS. 

Chapter  I — History".  Cause  and  Prevalence  of  Syphilis. 

The  Origin  of  the  Name 59 

Syphilis,  a  Master  Disease 59 

The  Historical  Aspects  of  Syphilis 60 

The  New  Knowledge  of  Syphilis 61 

The  Discovery  of  the  Germ  and  the  Transmission  of  Syphilis  to 

Animals 61 

The   Spirochaeta   Pallida   and    its   Recognition  in  Early    Syphilitic 

Sores  62 

The  Prevalence  of  Syphilis 63 


Chapter  II — The  Course  of  Syphilis — Primary  and  Secondary  Stages. 

PAGE 

The  Stages  of  Syphilis 65 

_  The  Primary  or  Localized  Stage — The  Chancre 65 

Qure  in  the  Early  Stage  (Abortive  Cure) 66 

Difficulties  in  Recognizing  a  Syphilitic  Chancre 66 

The  Spread  of  the  Germs  from  the  Chancre  to  the  Body 67 

The  Generalized  or  Secondary  Stage 68 

Syphilitic  Eruptions  and  Their  Variations ;  Common  Misconceptions  68 

Syphilitic  Eruptions  and  the  General  Public . . : 69 

-The  Dangerous  Contagious  Manifestations  of  Secondary  Syphilis..  69 
The   Constitutional   Effects    of    Secondary    Syphilis ;    Symptomless 

Syphilis    70 

Chapter  III— Recurrent,  Inactive  and  Late  Syphilis. 

Latent,  Obscure  or  Silent,  and  Recurrent  Syphilis . . . .  r 71 

Contagious  Recurrences  and  Inefficient  Treatment 71 

Silent  or  Latent  Syphilis  and  Late  Complications 72 

Late  Syphilis — Premature  Old  Age  and  Gummatous  Change 73 

The  Hopeful  Side  of  Late  Syphilis 74 

Late  Syphilis  of  the  Nervous  System — Locomotor  Ataxia  and  Gen- 
eral Paralysis   74 

Late  Syphilis  is  Preventable  and  Treatable 75 

Chapter  IV — Modern  Tests  for  the  Recognition  of  Sy'philis. 

Laboratory  Tests  vs.  Medical  Examination  in  Syphilology 76 

The  Wassermann  Blood  Test  for  Syphilis 77 

Personal  Equation  and  Interpretation  in  the  Wassermann  Test 78 

The  Positive  Wassermann  Test 78 

The  Negative  Wassermann  Test 79 

Effect  of  Treatment  on  the  Blood  Test 79 

The  General  Medical  Examination  Essential 80 

Spinal  Fluid  Tests 80 

Chapter  V^Hereditary"  Syphilis. 

Effect  of  Syphilis  on  the  Race 82 

The  Syphilitic  Mother 82 

Mode  of  Infection  of  the  Child , 82 

Treating  the  Mother  May  Protect  the  Unborn  Child 83 

Effect  of  Inherited  Syphilis  on  the  Child 83 

Symptoms  of  Syphilis  in  the  New-Born 84 

Late  Effects  of  Inherited  Syphilis ;  Imbecility,  Eye  and  Ear  Troublje  84 

Hereditary  Syphilis  and  the  Third  Generation 85 

Public  Responsibility  in  Hereditary  Syphilis 85' 

Chapter  VI — The  Treatment  of  Syphilis. 

The  Treatment  of  Syphilis  with  Mercury 86 

Mercury  Does  Not  Control  Contagiousness 87 

The  Discovery  of  Arsphenamino — Ehrlich's  "60G'' 87 

The  Commercial  Status  of  Arsphenamine 88 

The  Fallacy  of  the  One-Dose  Cure 89 

The  Action  of  Arsphenamine 89 

8 


Chapter  VII — The  Cure  of  Syphhjs.  page 

What  is  Adequate  Treatment? 91 

An  Interpretation  of  the  Cure  of  Syphilis 91 

The  Time  Factor  in  Cure 92 

Determination  of  the  Fact  of  Cure 92 

Treatment  of  Hereditary  Syphilis '    93 

Chapter  VIII — Public  and  Personal  Hygiene  of  Syphilis. 

Summary  of  Facts  Regarding  Contagiousness 94 

Non-Genital   Syphilis 94 

The  Engagement  Chancre 95 

Genital  Transmission  of  Syphilis 95 

Duration  of  Contagiousness.     Effect  of  Tobacco,  Dirt,  etc 95 

Arsphenamine  in  the  Control  of  Contagiousness  in  Syphilis 95 

Personal  Responsibility  in  the  Transmission  of  Syphilis 96 

Chapter  IX — Syphilis  and  Marriage. 

Syphilis  and  the  Medical  Examination  before  Marriage 98 

Responsibility  of  the  Church ; 99 

Responsibility  of  the  Medical  Profession 99 

Summary  of  the  General  Outlook 100 


PART  IV. 


THE  SOCIAL,  PSYCHOLOGIC,  AND  ECONOMIC  BACKGROUND 
OF  SYPHILIS  AND  GONORRHEA. 
Chapter  I — The  Public  Viewpoint. 

The  Inertia  of  Public  Opinion 103 

An  Analysis  of  Current  Misconceptions 104 

Public  Ignorance  of  the  Facts 104 

Confusion  with  the  Problem  of  Prostitution 105 

Exaggerated  Notions  about  Contagiousness 106 

The  Fallacy  of  Believing  Fear  a  Deterrent 106 

A  Positive  Idealism  Necessary 107 

"I  Thank  Thee  That  I  am  not  as  Other  Men  Are" 107 

Syphilis  and  Gonorrhea  as  "Frightf ulness" 108 

Chapter  II — Normal  Ideals  of  the  Sex  Life — Abnormal  Checks  on 
Marriage.  The  Trend  of  the  Times  to  Laxity — The  Influence  of 
the  War. 

The  Normality  of  Sex  Ideals 110 

The  Changing  Trend  of  Sex  Ideals 110 

,       Growing  Need  for  a  Bulwark  of  Moral  Ideals 110 

Remediable  Obstacles  and  Factors  of  Error  in  Marriage Ill 

Training  in  the  Ideals  and  Practicalities  of  Marriage Ill 

Marriage  and  Industrial  Dependence 112 

The  Effect  of  Failure  on  Marriage  Ideals 112 

Marriage  and  the  Economic  Treadmill 113 

The  Tendency  of  Sex  Life  to  Crudity  of  Expression 114 

The  Trend  Toward  Sexual  Laxity;  Decadence  of  Chaperonage 114 

Contributions  Made  by  the  War  to  Sex  Problems , 115 


Chapter  III — The  Economic  Background  of  Syphilis  and  Gonorrhea 
— Prostitution — Alcoholism   and  the  Genital  Infections — Other 

Forms  of  Commercial  Exploitation.  page 

The  Dollars  and  Cents  Aspect 116 

Cost  of  Treatment  as  an  Element  in  the  Campaign 117 

Commercialization  of  the  Sex  Impulse 117 

Syphilis  and  Gonorrhea  in  Prostitutes 118 

The  Medical  Examination  of  Prostitutes 118 

Syphilis  in  the  Lax  and  Indiscrete 119 

Unsocial  Sexual  Relations  Cannot  be  Made  Safe 119 

The  Struggle  Against  Prostitution;   Regulation,  Repression,  Legal 

Measures   119 

State  Care  of  Delinquent  Girls 120 

The   Fundamental  Principle 121 

Alcoholism  and  the  Acquiring  of  Syphilis  and  Gonorrhea 121 

Physiologic  Effects  on  Persons  Already  Infected 121 

Other  Phases  of  Commercial  Exploitation  of  Sex ;  the  Stage,  Books, 

Clothes,    etc 122 

Chapter  IV — ^Moral  and  Educational  Prophylaxis  of  Syphilis  and 
Gonorrhea — Problems  and  Methods  of  Sex  Education. 

Morale  and  the  Sexual  Life 123 

Positive  Idealism  and  Idealistic  Expression 123 

Altruistic  Outlets  for  Sexual  Energy 123 

The  Fundamental  Inhibitions;  Sound  Character  as  a  Basis  of  Self 

Control 124 

Teach  the  Child 125 

Home,  Protection  and  the  Work  Outlet  in  Sex  Education 125 

Virginity  is  only  Half  the  Problem 125 

Value  of  Sex  Instruction 126 

Methods  and  Technic  of  Sex  Instruction 126 

Companions  and  Books v 127 

Good   Sportsmanship   and   Hardy  Living 128 

The  Time  for  Plain  Facts 128 

Visual,  Graphic  and  Personal  Teaching;  the  Spealver 128 

Chapter  V — The  Public  Health  Control  and  Personal  Prophylaxis 
OF  Syphilis  and  Gonorrhea. 

The  Public  Health  Control  of  Syphilis  and  Gonorrhea 130 

The  Church  and  the  Problem 130 

The  New  Responsibilities  of  the  Medical  Profession 130 

Hospitals  and  the  Problem 131 

The  Press  and  the  Problem 132 

Laws  and  Law  Enforcement ;  Compulsory  Treatment 133 

The  Reporting  of  Syphilis  and  Gonorrhea  to  Health  Officers 134 

Legislation  Needed  on  Medical  Professional  Confidence '. 134 

Personal  Prophylaxis ;  Continence 135 

The  Medical  Prevention  of  Syphilis  and  Gonorrhea 135 

Conclusion    136 


11 


AUTHOR'S  PREFACE 

j-n  the  past  fifty  years  the  socialization  of  mediciue  has  paralleled  the  cen- 
tralization of  commerce  and  the  organization  of  labor.  It  is  no  longer  possible 
for  the  individual  physician  to  maintain  the  isolation  and  the  arbitrary  powers 
and  responsibilities  which  were  his  in  primitive  times.  The  advance  of  both 
the  art  and  the  science  of  medicine  has  compelled  the  development  of  partner- 
ships and  group  practice,  in  which  the  knowledge  of  one  man  supplements  the 
lacks  of  another,  to  the  advantage  of  the  sick  for  whom  and  upon  whom  they 
work.  As  this  idea  of  cooperative  effort  develops  within  medicine  itself,  a 
new  form  of  relationship  in  the  maintenance  of  human  welfare  appears  upon 
the  horizon.  A  partnership  between  intelligent  and  well  informed  public 
opinion  and  the  physician  as  leader  is  the  logical  ultimate  expression  of  the 
trend  of  the  times.  Medicine  is  beset  with  problems  whose  solution  is  impos- 
sible except  by  the  widest  cooperation  and  the  broadest  understanding  imagin- 
able. The  physician  as  a  leader  acting  alone  is  helpless.  It  was  said  of  the 
Roman  legion  that  its  tremendous  effectiveness  as  against  the  phalanx  was 
due  to  the  fact  that  every  man  in  it  was  an  accomplished  warrior  who  could, 
if  alone,  give  admirable  account  of  himself.  To  make  every  intelligent  man, 
woman  and  child  a  legionary  in  the  organization  of  the  public  health,  some 
of  the  knowledge  so  long  sedulously  kept  as  the  property  of  the  profession  of 
medicine  must  be  imparted  to  the  rank  and  file. 

One  by  one  the  greatest  scourges  of  the  race  are  succumbing  to  this  new 
strategic  method.  Malaria  and  yellow  fever  are  giving  way  not  alone  before 
the  advance  of  medical  knowledge,  but  also  before  the  popularizing  of  that 
knowledge  which  makes  every  day  people  intelligent  cooperators  in  the  cam- 
paign. Tuberculosis  mortality  is  falling,  not  alone  because  of  new  conceptions 
in  its  treatment,  but  because  of  the  tremendous  force  of  public  knowledge  and 
sentiment.    In  time  the  same  fate  will  await  cancer,  syphilis  and  gonorrhea. 

Syphilis  and  gonorrhea  perhaps  more  than  any  other  of  the  great  plagues 
which  scourge  humanity,  need  the^  new  strategic  method.  Medically  we  are 
armed  to  the  teeth  against  them.  All  the  paraphernalia  of  battle  is  at  hand. 
Against  these  two  diseases  we  can  move  with  irresistible  force  on  the  dawn 
of  the  day  of  human  enlightenment.  That  dawn  is  very  near.  Once  we  can 
open  the  eyes  of  the  every  day  man  and  woman  to  see  the  enemy  as  he  is,  his 
course  is  run. 

There  is  no  device  known  to  a  cruel,  unscrupulous  and  implacable  opponent 
which  has  not  been  used  against  us  by  the  twin  scourges.  They  have  crept 
into  our  houses  and  murdered  the  innocent  and  the  helpless.  They  have  ap- 
peared to  many  a  sincere  well-wisher  of  mankind  not  in  their  true  semblance 
of  brutal,  wanton  and  savage  mutilators  and  destroyers,  but  in  the  disguise  of 
well-wishers,  guardians  of  the  moral  life,  painful  but  just  chasteners  of 
iniquity.  Many  a  sincere  but  uninformed  or  unthinking  man  or  woman  has 
shuddered  to  think  that  these  things  must  be,  and  yet  feared  to  protest  against 
them,  refused  even  to  know  about  them  lest  with  one  horror  removed  or  ex- 
plained away,  they  should  confront  a  worse  one.  We  have  lived  the  nightmare 
of  one  who  dreams  that  his  awakening  will  be  his  death,  and  dares  not  open 
his  eyes. 

Syphilis  and  gonorrhea  are  not  what  public  misconception  makes  them. 
Quietly  and  dispassionately  examined,  they  can  be  easily  seen  to  be  no  more  dis- 
reputable than  other  disease  enemies  of  the  race.  They  have  likewise  no  super- 
nal power  or  commission.     They  are  no  more  repellent  to  the  senses  than  many 

13 


auottier  ailmeut.  There  is  notliiug  iu  their  origin  which  gives  us  cause  to  re- 
fuse to  know  about  them.  In  fact  an  understanding  of  them  is  the  more 
obligatory  upon  us  because  they  undermine  and  attack  the  citadel  of  life  itself. 
Thfe  clothing  of  mysterious  words  and  allusions,  of  shame-fast  silence,  of  false 
disgrace,  of  painted  horror  that  surrounds  them  is  their  cloak  of  darkness 
which  protects  them  from  the  vengeance  we  would  visit  on  intimate  and  secret 
enemies.  Like  murderers  who  mingle  with  the  crowd  upon  the  very  scene  of 
their  crime,  syphilis  and  gonorrhea  stand  so  near  to  us  that  although  they  have 
attacked  our  very  germ  plasm  and  our  physical  immortality,  we  have  not 
known  them  for  what  they  are. 

The  movement  for  a  new  conception  of  these  two  diseases,  which  will  make 
the  common  man  a  legionary,  and  will  enlist  against  syphilis  and  gonorrhea 
all  the  force  of  an  enlightened  public  sentiment,  begins  with  a  choice  of  words. 
The  armor  of  the  third  and  fourth  great  plagues  is  words.  For  generations 
syphilis  and  gonorrhea  have  been  called  venereal,  until  the  mere  use  of  the 
term  throws  a  cloak  of  odium  over  any  subject  to  which  it  is  attached.  Peo- 
ple are  afraid  of  it,  afraid  of  being  shocked,  afraid  of  being  besmirched,  of 
having  the  loathsome  thrust  upon  them.  And  all  this  repulsive  connotation, 
wholly  uncalled  for  as  it  is,  plays  into  the  hand  of  syphilis  and  gonorrhea. 
Labels  that  attract  lead  us  to  scrutinize  the  object.  Labels  that  repel,  turn 
away  our  gaze  and  foster  ignorance.  Much  of  our  public  attitude  toward 
syphilis  and  gonorrhea,  our  false  modesty  and  mistaken  shame,  our  ultra- 
sexual  point  of  view,  is  the  product  of  false  labelling.  To  look  at  syphilis  and 
gonorrhea  with  the  verbal  veil  withdrawn  is  not  to  turn  to  stone  before  the 
Medusa  gaze,  but  to  be  inspired  to  dash  at  the  monster  and  demolish  it.  To 
withdraw  the  veil  and  permit  people  to  face  the  facts,  is  the  first  function  of  a 
public  health  movement  against  the  "diseases  of  vice." 

A  dispassionate  and  calm  analysis ;  good  Anglo-Saxon  words ;  the  simple 
dignity  of  truth-telling;  iteration  and  reiteration,  will  yet  awaken  a  sleeping 
public  thought  to  the  enemy  within  our  gates. 


14 


PART  I. 
THE  NATURE  OF  THE  GENITAL  INFECTIONS. 


CHAPTER  I. 
THE  SOURCE  OF  THE  GENITAL  INFECTIONS. 

The  Genital  Injections  Defined. — There  are  more  than  merely 
psychological  grounds  for  avoiding  the  tendency  to  group  the  four 
so-called  "venereal  diseases"  syphilis,  gonorrhea,  chancroid  and 
gangrenous  balanitis,  together  under  a  single  head.  The  history 
of  these  four  infections  is  rich  in  examples  of  the  retarding  effect  on 
knowledge,  of  a  premature  inclusion  in  one  conception  df  several 
different  ailments  merely  because  of  the  accident  of  their  beginning 
on  the  same  part  of  the  body.  To  be  sure,  syphilis,  chancroid  and 
gangrenous  balanitis  begin  as  sores.  Yet  the  latter  two  of  the  sores 
have  ahead  of  them  when  they  appear,  only  a  brief  and  usually  a 
trivial  history.  Prompt  and  complete  recovery,  without  any  more 
than  local  damage  to  the  genitals,,  is  the  rule.  The  first  sore  of 
syphilis,  on  the  other  hand,  has  from  the  moment  of  its  appearance, 
a  significance  which  reaches  potentially  into  every  tissue  of  the 
patient's  body  and  into  every  hour  of  his  succeeding  days  and  years. 
It  reaches  beyond  him  into  the  lives  of  his  intimates  and  his  friends, 
into  his  career  and  all  that  it  may  touch,  and  through  the  children 
that  may  or  may  not  be  his,  it  lays  hands  upon  the  future  of  the  race. 
Gonorrhea  instead  of  beginning  as  a  sore,  begins  as  a  discharge  of 
pus  from  the  canal  through  which  the  urine  flows,  or  in  women  often 
as  an  inflammation  of  some  deeper  portion  of  the  genital  tract.  In 
the  large  majority  of  cases  its  field  of  action  is  local,  the  damage 
that  it  does  the  race  being  inflicted  mainly  through  its  power  to  in- 
jure and  incapacitate  the  structures  that  create  and  bring  children 
into  the  world.  Syphilis  in  the  overwhelming  proportion  of  cases 
carries  consequences  for  the  individual  that  have  a  quality  of  seem- 
ing remoteness,  a  potential  gravity  and  an  element  of  surprise  which 
make  it  stand  alone  among  all  human  ailments.  Between  the  tiny 
genital  sore  and  the  doddering  victim  of  syphilitic  insanity  there  is 
a  vast  gulf  of  alarms  and  tragic  possibilities.  Gonorrhea  is  more 
of  an  inch-by-inch  disease,  less  versatile  and  less  dramatic  than 
syphilis,  and  in  proportion  to  its  wider  distribution,  perhaps  less 
inexorable  and  implacable.  It  is  none  the  less  a  tenacious,  stub- 
born and  mean-spirited  foe. 

It  will  be  worth  while  to  bear  in  mind  that  for  the  broader  out- 
look, the  genital  diseases  are  really  only  two  in  number — syphilis 
and  gonorrhea.  Chancroid  and  gangrenous  balanitis  are  incidents 
in  the  diagnosis  of  syphilis.  Gonorrhea  is  a  wholly  different  prob- 
lem from  every  point  of  view.     There  is  no  longer  any  need  to  speak 

17 


18 

of  the  venereal  diseases.  If  we  must  choose  two  words,  let  it  be  the 
two  that  have  the  ring  of  frankness  and  the  grace  of  simplicity  and 
directness — syphilis,  gonorrhea. 

General  Principles  of  Transmission  of  Genital  Infections. — Cer- 
tain fundamental  facts  apply  no  less  to  syphilis,  gonorrhea  and  their 
satellites,  chancroid  and  gangrenous  balanitis,  than  to  such  diseases 
as  diphtheria,  tuberculosis  and  pneumonia.  All  of  them  are  in- 
fections, each  produced  by  its  own  specific  germ.  They  are  trans- 
mitted by  the  physical  contact  of  the  well  person  with  some  inter- 
mediate object,  or  with  some  part  of  the  body  of  the  sick  one,  on 
which  are  present  the  germs  causing  the  disease  in  question.  If 
there  are  germs  of  syphilis  in  the  mouth,  contact  with  the  mouth  or 
with  objects  containing  secretions  from  the  mouth  will  give  the  dis- 
ease to  a  healthy  person.  The  transmission  of  disease  by  interme- 
diate objects  is  dependent  upon  the  length  of  time  and  the  condi- 
tions under  which  the  germ  in  question  can  live  outside  of  the  body. 
Unless  the  germ  is  carried  in  droplets  of  saliva,  as  sometimes  hap- 
pens in  certain  diseases,  there  is  no  vague  blowing  about  of  the 
poisonous  agent  in  mysterious  ways  from  place  to  place.  The  con- 
tact is  physical,  the  infection  by  actual  transfer  of  germs. 

Individual  Resistance,  Peculiarities  of  the  Germs. — A  third  fac- 
tor enters  into  the  transmission  of  infections,  in  addition  to  the 
infected  body,  and  the  intermediate  article  carrying  the  germs.  This 
is  the  so-called  resistance  of  the  well  person — his  ability  to  fight  off 
germs  that  try  to  gain  a  foothold  on  him.  While  this  is  a  large 
factor  in  protecting  well  people  from  certain  diseases,  it  plays  a 
little  understood  but  probably  very  minor  role  in  protecting  healthy 
persons  from  syphilis,  gonorrhea  xind  chancroid.  To  these  diseases 
practically  everybody  seems  to  be  susceptible — at  least  everybody 
can  acquire  them,  although  in  some  the  infection  may  run  a  milder 
course  than  in  others.  The  great  factor  which,  in  the  last  analysis, 
protects  humanity  from  the  practically  universal  spread  of  syphilis 
and  gonorrhea  is  not  the  virtue  and  chastity  of  some  as  distinguished 
from  the  viciousness  of  others,  although,  to  be  sure,  foolhardy'  ex- 
posure increases  the  risk  of  acquiring  these  as  much  as  any  other 
infections — it  is  essentially  the  biological  characteristics  of  the 
germs  themselves  that  save  us.  Syphilis  and  gonorrhea  are  genital 
diseases,  but  not  because  some  far-seeing  power  set  them  as  watch- 
dogs at  the  gate  of  righteousness.  They  are  transmitted  by  sexual 
intercourse  and  by  intimate  contacts  between  person  and  person  (not 
necessarily  man  and  woman)  because,  like  the  homely  potato,  the 
germs  of  these  diseases  need  a  certain  soil  on  which  to  grow.  These 
germs  are  vegetables,  so  to  speak,  and  if  the  conditions  can"  be  made 
unfavorable  for  them  at  the  spot  on  which  they  are  planted,  no 


19 

amount  of  vice  and  immorality  connected  with  the  planting  can  per- 
suade them  to  grow.  Correspondingly,  innocence,  virtue  and  igno- 
rance have  no  power  to  retard  their  growth  upon  the  parts  of  the 
body  where  they  find  conditions  favorable.  The  absence  of  air  in  the 
genital  tract  of  a  saint  is  as  favorable  to  the  growth  of  the  germ  of 
syphilis  as  in  that  of  a  sinner.  It  makes  not  an  iota  of  difference 
whether  the  cause  is  just  or  unjust,  the  victim  innocent  or  be- 
smirched. No  one  would  go  so  far  as  to  say  that  collateral  habits 
of  dri.nkenness,  uncleanliness  and  bad  living  such  as  are  prevalent 
among  the  vicious,  do  not  favor  infection  with  these  as  with  all 
other  contagious  diseases.  But  there  is  no  connection  so  direct  as 
to  justify  the  title  of  venereal  as  applied  to  any  disease  to  mark  it 
as  a  punishment  for  sin. 

Intimate  Contact  and  Moisture  Necessary. — For  the  transmission 
of  syphilis  and  gonorrhea  in  general,  intimate  contacts  between 
moist  surfaces  are  essential.  Intimate  contact  between  the  male  and 
female  genitalia  however,  is  in  no  wise  essential.  A  syphilitic 
chancre  on  the  cheek  from  an  infected  razor  cut,  or  gonorrhea  in 
infants  from  contact  with  an  infected  diaper  is  just  as  much  syphilis 
or  gonorrhea  as  the  sexually  transmitted  type  that  so  completely 
occupies  the  horizon  of  popular  misconception.  Dry  materials  do 
not  transmit  these  diseases,  nor  does  infection  with  them  tend  to 
follow  invariably  upon  casual  contacts.  The  germ  of  gonorrhea  will 
not  grow  as  a  rule  upon  the  skin,  while  that  of  chancroid  will,  and 
that  of  syphilis  may  if  the  conditions  are  otherwise  favorable.  Door 
knobs,  the  walls  of  rooms,  linen  and  blankets  that  have  been  washed, 
for  example,  do  not  harbor  them.  Mild  antiseptics  usually  destroy 
them.  Yet  there  is  about  them,  and  about  the  germ  of  syphilis  es- 
pecially, an  uncanny  versatility.  Only  too  often,  where  every  pre- 
caution has  been  taken  they  manage  to  get  a  foothold  through  some 
trivial  slip,  and  where  they  are  least  expected,  they  appear.  In  fact 
it  is  too  often  those  ignorant  of  facts  and  risks  alike  who  are  be- 
trayed in  the  sacred  intimacies  of  life,  instead  of  in  its  unworthy 
moments.  The  human  genital  infections  are  parts  of  a  biological 
problem,  not  a  moral  issue.  Dourine,  a  disease  of  the  horse  which 
while  caused  by  another  germ  than  syphilis,  has  a  remarkable  re- 
semblance to  it  in  its  manifestations  and  its  sexual  transmission, 
can  hardly  be  conceived  of  by  any  reasonable  person  as  a  special  de- 
vice for  guarding  that  animal's  moral  life.  Yaws,  the  twin  brother 
of  syphilis  in  man,  a  tropical  disease  so  like  it  in  every  respect, 
even  to  the  germ  causing  it,  that  it  might  almost  be  called  syphilis, 
has  not  developed  the  unsavory  reputation  of  a  "venereal"  disease. 
Larger  considerations  such  as  these  soon  disabuse  even  the  preju- 
diced of  the  idea  that  there  is  moral  value  in  the  genital  infections 


20 

and  that  they  are  needed  to  safeguard  us  from  license.  They  are 
dangerous  contagious  diseases.  Their  value  to  mankind  as  a  source 
of  inspiration  and  uplift  is  nil.  Their  cost  in  undeserved  wretched- 
ness, in  innocence  put  to  torture,  in  physical  and  spiritual  degrada- 
tion is  immeasurable.  An  enlightened  conception  of  duty  to  the 
public  health  demands  that  we  blot  them  out. 


21 

CHAPTER  II. 
THE  GENITAL  SORE. 

Chancroid,  and  gangrenous  balanitis,  are  mere  appendages  of  the 
problem  of  syphilis,  and  derive  practically  all  of  their  significance 
from  the  fact  that  being  sores  on  the  genitals,  they  may  conceal  be- 
neath a  seemingly  harmless  exterior,  a  much  graver  infection. 
Syphilis  begins  with  a  pimple,  ulcer  or  sore  at  the  point  where  the 
germs  enter  the  body.  While  it  has  long  been  recognized  that  mixed 
infections  with  chancroid  and  syphilis  could  occur,  it  was  not  until 
the  discovery  in  1905  of  the  germ  causing  syphilis  that  a  reliable 
and  widely  applicable  method  of  distinguishing  a  syphilitic  from  a 
chancroidal  sore  by  the  microscope  was  developed.  This  will  be 
more  fully  discussed  in  connection  with  syphilis. 

Antiquated  Distinctions  hetiveen  Syphilitic  and  Chancroidal 
Sores. — Physicians  of  the  older  school,  and  unfortunately  too  many 
younger  men,  have  been  taught  an  elaborate  lore  or  diagnostic  sys- 
tem for  distinguishing  chancroid  from  chancre  (syphilis)  on  the 
score  of  the  appearance  of  the  ulcer  alone.  By  this  method,  of 
course,  typical  text-book  picture  chancres  may  be  recognizable,  but 
in  general  it  may  be  said  that  the  first  sore  of  syphilis  is  quite  as 
often  unlike  the  pictures  in  books,  as  it  is  like  them.  The  etfort  to 
distinguish  the  two  by  their  appearance  has  in  general  done  vastly 
more  harm  than  good,  since  innumerable  syphilitic  sores  have  been 
mislabelled  chancroids  by  victims  who  have  picked  up  a  little  half- 
knowledge  on  the  matter,  and  by  physicians  not  familiar  with  the 
very  large  margin  of  error  in  such  judgments.  It  may  be  absolutely 
impossible  to  distinguish  the  sore  marking  the  beginning  of  syphilis 
from  any  one  of  the  half-dozen  other  types  of  sores  which  may  appear 
upon  the  genitals.  "Hair  pimples,"  "warts,"  "chafes,"  the  bites  of 
the  itch  mite,  the  blisters  of  a  "cold  sore,"  the  plainest  and  most 
undoubted  chancroid  that  ever  was,  may  each  and  every  one  be  the 
first  sore  of  syphilis.  When  a  sore  of  any  description  appears  upon 
the  genitals  of  a  person  who  has  had  sexual  intercourse  or  intimate 
contact  with  another,  the  first  problem  of  the  physician  is  to  prove 
that  that  sore  is  not  syphilitic. 

Modern  Methods  for  Recognizing  Early  Syphilis. — There  are  only 
two  ways  of  proving  that  a  sore  is  not  the  beginning  of  syphilis. 
The  first  of  these  is  failure  to  find  the  germ  of  syphilis  after  repeated 
careful  examinations  with  the  microscope.  The  second  is  repeatedly 
to  test  the  blood  of  the  patient  for  evidence  of  syphilis  through  a 
period  of  not  less  than  three  months  from  the  time  the  sore  first  ap- 
peared. The  second  of  these  procedures  is  never  to  be  made  a  sub- 
stitute for  the  first,  since  a  sore  can  be  proved  to  be  a  chancre,  the 


22 

beginning  of  syphilis  by  microscopic  examination,  long  before  it  can 
be  proved  to  be  such  by  the  blood  test.  Neither  is  it  permissible  to 
substitute  mere  waiting  for  a  ''breaking  out"  or  eruption  to  develop, 
since  the  blood  test  usually  becomes  positive  first,  and  the  eruption 
may  be  so  trifling  as  to  be  overlooked  or  misunderstood.  In  the 
modern  treatment  of  syphilis,  hours  count,  and  to  lose  them  by  wait- 
ing for  a  blood  test  to  show  the  disease  because  one  is  too  ignorant, 
indifferent  or  inexperienced  to  find  the  germ  itself  in  the  secretions 
from  the  sore,  is  fast  becoming  criminal  negligence. 

Early  Examination  and  No  Previous  Treatment. — In  order  to 
make  it  possible  to  prove  the  nature  of  a  sore  by  microscopical  ex- 
amination, and  the  finding  of  the  germ,  two  things  are  absolutely 
essential  in  addition  to  the  necessary  equipment  and  knowledge  on 
the  part  of  the  doctor.  The  first  is  that  the  sore  shall  have  had  no 
treatment  of  any  kind,  whether  applied  to  the  sore,  or  given  to  the 
patient  internally.  The  second  element  is  time.  The  sore  must  be 
seen  early.  The  germs  of  syphilis  are  fragile  and  yet  tremendously 
tenacious.  A  little  dusting  powder  of  almost  any  kind,  a  wash  even 
of  boric  acid,  may  kill  or  drive  them  from  the  surface  of  the  sore. 
But  in  the  deeper  tissues,  where  they  are  much  harder  to  reach  and 
may  not  be  found  at  all,  they  may  continue  to  thrive.  The  sore  may 
even  heal  over  above  them,  and  the  patient  yet  develop  syphilis.  If 
the  sore  has  not  been  treated,  all  that  is  necessary  to  obtain  them  is 
to  clean  off  the  surface  with  gauze  or  scrape  it  very  lightly,  and  the 
serum  that  comes  out  will  swarm  with  them.  It  is  safe  to  say  that 
every  year  tens  of  thousands  of  men  unknowingly  throw  away  a  one 
hundred  per  cent  possibility  of  being  cured  of  syphilis  by  listening  to 
gome  friend  who  advises  them  to  "dry  it  up  with  calomel  powder," 
or  by  accepting  the  ever  ready  advice  of  Joe  the  drug  clerk  at  the 
Fixall  Store,  only  to  find  a  few  weeks  or  a  few  years  later  that  the 
disease  has  them  by  the  throat.  Too  often  the  doctor  himself  is  the 
man  who  "burnt  it  off"  and  let  it  go  at  that,  or  allowed  the  patient 
to  believe  that  healing  means  "chancroid"  and  not  syphilis.  Em- 
phasis, too,  must  be  laid  upon  the  word  repeated,  wherever  it  occurs. 
Repeated  microscopic  examinations,  three  or  four — repeated  blood 
tests,  so  as  to  catch  the  first  signs  of  the  disease  in  the  blood,  are 
part  of  the  modern  requirements.  Their  expense  is  trifling  com- 
pared with  the  expense  of  the  additional  months  and  years  of  treat- 
ment and  the  increased  risks  that  delay  in  recognition  of  a  syphilitic 
infection  entails. 

The  Microscopic  Examination  is  Essential. — Let  it  be  said  again, 
that  there  is  no  way  of  describing  or  picturing  chancroid  and 
gangrenous  balanitis  which  can  exclude  the  possibility  of  their  being 
the  beginning  of  syphilis.     Whether  the  sore  is  hard  or  soft,  single 


33 

or  many,  painful  or  painless,  pinhead  or  silver  dollar  size,  the  day 
is  passed  when  physician  or  layman  can  look  at  it,  pinch  it,  feel  the 
kernels  or  glands  in  the  groin  and  dramatically  say  the  fateful  word 
that  brings  joy  or  lamentation,  "chancroid"  or  "syphilis."  No 
patient  should  be  content  with  such  an  examination,  or  with  the  in- 
numerable names  such  as  "chafe,"  "cold  sore,"  or  the  laugh  and 
"pooh-pooh"  which  may  be  offered  him  by  friend  or  doctor  as  a  reas- 
surance. Experts  may  occasionally  be  able  to  judge  cases  on  their 
merits  and  decide  without  examination  that  a  group  of  blisters  on 
the  genitals  of  a  man  or  woman  who  has  not  had  sexual  contact  is 
not  syphilis.  But  in  general  the  less  leeway  the  better  and  the  more 
unvaryingly  the  patient  demands  and  the  physician  carries  out  the 
proper  microscopical  examination  of  genital  sores,  followed  by  the 
repeated  testings  of  the  blood  if  the  germs  are  not  found,  the  more 
syphilis  will  be  recognized  in  time  for  cure  and  the  fewer  men  will 
have  the  experience  so  distressingly  common  in  these  days,  of  find- 
ing that  a  mere  label  like  "chancroid,"  glossed  over  the  syphilis  that 
wrecked  them  when  they  reached  their  prime.  The  public  has  a 
duty  in  demanding  service  of  this  type  from  the  medical  profession, 
quite  as  much  as  the  profession  has  a  duty  in  furnishing  it,  and  the 
pressure  of  a  public  conception  of  what  the  doctor  ought  to  do  in 
such  a  case  will  hasten  the  day  when  the  doctor  will  be  ready  and 
able  to  do  it. 

Reassurance  for  the  Timid. — Positive  statements  like  the  forego- 
ing, true  though  they  may  be,  have  a  trick  of  upsetting  the  nervous 
and  timid,  usually  those  for  whom  the  admonitions  are  least  in- 
tended. For  the  benefit  of  such,  let  it  be  said  that  the  presumption 
of  syphilitic  infection  is  proportional  in  some  degree  to  the  amount 
of  exposure,  and  that  men  and  women  who  are  continent  are  not 
at  all  likely  to  develop  genital  sores  or  gonorrhea  from  the  many 
harmless  outside  contacts  with  toilets,  door  knobs,  bathtubs  and 
people,  which  nervous  persons  are  inclined  to  fear. 

The  True  Chancroid. — A  true  chancroid,  or  a  gangrenous  balanitis, 
in  spite  of  the  relative  insignificance  into  which  it  subsides,  once  the 
question  of  a  syphilitic  element  is  eliminated,  can  none  the  less  be  an 
exciting  and  highly  disagreeable  affair.  Little  sympathy  need  be 
wasted  on  the  average  chancroid,  or  on  any  gangrenous  balanitis, 
since  they  are  both  distinctly  venereal  in  the  overwhelming  majority 
of  cases^  and  filthily  so  at  that.  While  the  average  chancroid  runs 
the  course  of  an  infected  ulcer,  which  under  proper  treatment  be- 
comes clean  and  heals  with  only  a  small  amount  of  scarring,  small 
chancroids  especially  have  a  habit  of  sending  infection  up  into  the 

^  There  seems  to  be  a  type  of  sangrenons  ulcer  of  the  genitals  which  is  non- 
venereal,  and  there  are  forms  of  genital  ulceration  in  women  (ulcus  acutuni  vulvae) 
which   have  no  connection  with  rhancroiclal  infection  nnr)   yet  closely  resemble  it. 


24 

kernels  in  the  groin,  wliicli  swell,  become  intensely  painful  and  usual- 
ly have  to  be  lanced — a  "bubo,"  as  this  complication  is  called.  Larger 
chancroids  leave  ineradicable  labels  in  the  form  of  loss  of  tissue  and 
scarring  as  reminders.  The  common  chancroid  often,  and  gangren- 
ous balanitis  almost  always,  show  a  tendency  to  spread.  A  little 
unwise  interference,  and  often  no  apparent  cause,  is  sufficient  to 
make  them  violent.  Such  a  "phagedenic"  or  devouring  chancroid 
may  in  a  few  hours  leave  the  testicles  hanging  by  shreds,  the  re- 
mainder of  the  genitalia  nothing  but  ragged  bloody  stubs,  and  not 
content  with  this,  will  march  up  onto  the  abdomen,  melting  every- 
thing before  it.  Gangrenous  balanitis  produces  equally  horrible 
mutilations.  The  chancroid  certainly  lacks  nothing  in  physical 
characteristics  when  once  aroused  to  make  it  a  means  of  employing 
fear  for  educational  purposes.  Its  treatment  in  serious  cases,  too, 
causes  physical  agony  that  comes  as  near  the  German  conception  of 
frightfulness  as  any  single  experience  vouchsafed  a  human  being 
in  peaceful  life.  Even  in  the  serious,  multilating  chancroids,  in 
which,  when  the  patient  is  first  seen,  conditions  are  such  that  no 
microscopical  examination  for  the  germs  can  be  made  with  any  hope 
of  success,  the  ever  present  possibility  of  an  underlying  syphilis  must 
not  be  overlooked,  and  the  patient  cannot  be  regarded  as  well  until 
blood  tests  taken  as  late  as  four  months  after  the  infection  have 
shown  he  does  not  have  syphilis. 


PART  II.    GONORRHEA. 


37      , 

CHAPTER  I. 
HISTORY,  CAUSE  AND  PREVALENCE. 

Gonorrhea  a  Localized  Resistant  Infection. — We  pass  now  from 
the  prelude  of  the  local  phase  of  genital  infections  to  the  considera- 
tion of  two  of  the  greatest  modern  problems  in  disease.  Of  the  two, 
gonorrhea  presents  the  more  depressing  picture.  Its  enormous  prev 
alence  and  the  terrible  and  tragic  costs  which  it  entails  upon  un- 
comprehending mankind,  give  it  a  leading  place  among  the  scourges 
of  the  race.  Its  bulldog  obstinacy,  and  slowness  of  response  to  treat- 
ment, its  ability  to  baffle  every  resource  brought  against  it,  and  its 
trickery,  seem  to  give  it  all  the  attributes  of  an  evil  personality. 
Curable  to  be  sure,  and  usually  cured  under  prolonged  skillful  direc- 
tion, we  are  not  wholly  able  to  lay  our  hands  on  the  factors  that 
make  success  in  its  treatment.  "Nature"  seems  to  bear  too  large 
a  hand,  and  medical  skill  to  have  too  little  power  to  give  work  with 
the  disease  the  fascination  there  is  in  treating  syphilis.  There  is 
little  of  the  dramatic  about  its  treatment.  Dogged  persistence  on 
the  part  of  the  doctor  and  a  liberal  share  of  knowledge  as  to  what 
not  to  do  as  well  as  what  to  do,  with  a  cooperation  from  the  patient 
which  is  rarely  forthcoming,  constitute  the  essentials  of  the  medical 
management. 

Gonorrhea  is  an  infection  due  to  a  germ  which  on  its  appropriate 
tissue  soil  produces  inflammation  and  the  formation  of  pus  or  mat- 
ter. It  is  essentially  a  local  disease  of  the  genital  tract  in  both  the 
male  and  the  female.  It  may  extend  to  the  body  as  a  whole  in  a 
limited  percentage  of  cases,  causing  usually,  however,  only  a  re- 
stricted range  of  symptoms.  The  germ  of  gonorrhea  thrives  upon 
certain  tissues  in  addition  to  those  of  the  genital  tract,  notably 
those  of  the  conjunctiva  of  the  eye.  Gonorrheal  inflammation  of 
the  eye  or  gonorrheal  ophthalmia  in  childhood  is  so  common  and  so 
terrible  a  disease  as  to  deserve  to  rank  as  a  scourge  in  itself  alone. 

The  History  of  Gonorrhea. — Gonorrhea  is  a  disease  of  ancient  line- 
age. In  the  Brugsch  papyrus  attributed  to  the  year  1350,  B.  C, 
there  appear  among  the  remnants  of  an  Egyptian  system  of  medical 
practice,  references  to  symptoms  and  treatment  which  would  seem 
almost  certainly  to  apply  to  gonorrhea.  Jean  Astruc  described  it 
in  1736.  The  disease  emerges  from  the  obscurity  of  the  Middle 
Ages  in  time  to  be  confused  with  syphilis  by  such  men  as  Paracelsus, 
a  misconception  which  persisted  through  the  next  three  centuries 
and  did  much  to  retard  the  progress  of  knowledge.  Morgagni  dur- 
ing the  early  eighteenth  century  gave  an  account  of  the  complica- 
tions of  gonorrhea,  which,  in  view  of  the  miconceptions  of  his  time, 
was  remarkable  for  its  insight  and  completeness.     In  the  late  eight- 


,28 

eenth  century  the  immense  influence  of  John  Hunter  gave  renewed 
impetus  to  the  already  existing  misconceptions  of  the  relations  be- 
tween syphilis  and  gonorrhea.  With  commendable  but  unfortunate 
courage  he  inoculated  himself  with  the  pus .  from  a  patient  with 
gonorrhea.  It  happened  that  the  patient,  as  we  now  know,  had 
syphilis  also,  and  Hunter  developed,  not  gonorrhea,  but  syphilis. 
He  believed  from  this  experiment  that  the  two  were  identical  and 
the  weight  of  his  medical  authority  was  such  that  it  took  another 
generation  under  the  leadership  of  the  great  Frenchman,  llicord,  to 
set  the  matter  right.  While  Rollet  in  the  middle  of  the  nineteenth 
century  had  insisted  upon  the  special  identity  of  gonorrhea,  it  re- 
mained for  Neisser  the  famous  urologist  and  syphilographer  of  Bres- 
lau  to  identify,  in  1879,  the  true  cause  of  gonorrhea.  With  this  dis- 
covery— one  of  the  really  great  facts  in  the  history  of  medicine — the 
modern  methods  for  the  recognition  of  the  disease  in  early,  quiescent 
and  obscure  cases  were  developed,  and  the  microscope  assumed  con- 
trol over  the  field  in  precisely  the  way  that  it  did  later  in  early 
syphilis.  The  discovery  of  the  germ  did  not,  however,  give  the  cue 
for  the  brilliant  triumphs  in  treatment  that  were  made  possible  in 
syphilis  by  the  recognition  of  the  spirochaete  or  spiral  germ  which 
causes  that  disease.  The  non-transmissibility  of  gonorrhea  to  ani- 
mals has  decidedly  increased  the  difficulties  of  its  study,  and  has 
probably  delayed  the  progress  of  knowledge  on  treatment  as  much 
as  the  treatment  of  syphilis  has  been  advanced  by  the  fact  that  it. 
unlike  gonorrhea,  can  be  given  to  certain  animals  on  whom  it  is 
possible  to  carry  out  experimental  work. 

The  Gonococcus,  the  Cause  of  Gonorrhea. — The  gonococcus  of 
Neisser,  as  the  germ  of  gonorrhea  is  called,  is  one  of  a  type  of  round 
or  spherical  germs  known  as  the  cocci,  which  include  among  their 
numbers  such  common  enemies  of  humanitj^  as  the  pus  genns  that 
produce  boils  and  abscesses,  and  the  germs  of  pneumonia  and  of 
spinal  meningitis.  In  fact  the  gonococcus  seems  to  bear  a  striking 
resemblance  to  the  pneumococcus  and  the  meningococcus  both  in 
appearance  and  in  the  reactions  which  it  sets  up  in  the  body  tissues. 
Pus,  which  is  made  up  of  the  white  cells  of  the  blood  that  consti- 
tute our  first  line  of  defense  against  certain  germs,  is  usually  pro- 
duced in  abundance  by  a  gonococcal  invasion  during  its  early  or 
acute  stages.  Gonococci  are  very  minute,  and  can  be  found  in  the 
pus  only  by  the  higlier  powers  of  the  microscope,  after  it  has  been 
stained  with  certain  dyes.  The  germs  are  incapable  of  motion  and 
lie  either  free  in  the  pus,  or  more  often  inside  the  bodies  of  white 
blood  cells  that  have  devoured  them  in  their  struggle  against  tlie  in- 
vaders. In  the  latter  situation  they  usually  occur  in  pairs,  flattened 
somewhat  against  eacii  other  into  what  looks  for  all  the  world  like  a 


29 

coffee-bean.  Three  of  the  characteristics  of  the  gonococcus  provide 
the  quickest  and  on  the  whole,  most  reliable  method  of  identifying 
the  germs  in  recognizing  or  treating  the  disease:  (1)  their  reaction 
to  a  certain  method  of  staining  (Gram  stain)  in  which  the  gonococ- 
cus does  not  take  the  stain  itself  but  takes  a  "contrast  stain/'  while 
the  other  germs  of  similar  appearance  take  the  original  stain,  (2) 
their  presence  within  the  white  blood  cells,  (3)  their  typical  cotfee- 
bean  shape.  Gonococci  can  be  grown  on  certain  culture  media  in 
glass  tubes,  but  this  method  of  identifying  them  is  of  secondary  im- 
portance except  in  special  cases. 

The  Microscope  Essential  in  the  Treatment  of  Gonorrhea. — 
Gonorrhea  can  only  be  positively  identified  by  the  physician  after  a 
miscroscopic  examination  and  it  is  the  presence  or  absence  of  the 
germ  when  looked  for  in  the  way  described  that  determines  whether 
or  not  a  patient  who  has  had  gonorrhea,  is  well  or  still  has  the  dis- 
ease. Realizing  this,  it  at  once  becomes  apparent  that  the  same 
principle  applies  to  the  detection  of  gonorrhea  that  applies  to 
syphilis.  It  cannot  be  said  too  often  or  emphatically  that  the  find- 
ing of  the  germ  by  the  microscope  is  the  essential  point  in  the  game 
both  before  and  after  treatment.  The  patient  who  does  not  have 
the  benefit  of  such  examinations  or  who  does  not  abide  by  their  out- 
come, places  himself  voluntarily  or  through  ignorance  at  the  mercy 
of  medical  practice  little  better  than  that  of  the  Dark  Ages.  The 
physician  who  diagnoses  and  treats  gonorrhea  without  the  use  of 
the  microscope  never  knows  when  his  patient  is  free  from  the  in- 
fection. Such  a  physician  may  be  directly  responsible  for  all  the 
disastrous  sequels  to  an  uncured  gonorrhea  that  may  develop  in 
anyone  who  is  so  unfortunate  as  to  entrust  himself  to  his  care. 

The  Prevalence  of  Gonorrhea. — The  real  significance  of  gonorrhea 
will  be  better  appreciated,^  if  before  taking  up  its  symptoms,  some 
figures  are  offered  to  show  the  magnitude  of  the  problem.  It  should 
be  remembered  that  most  of  these  figures  are  estimates,  based  to  be 
sure  on  large  experience,  but  lacking  the  assured  correctness  of  prop- 
erly gathered  statistics.  Accurate  vital  statistics  on  a  disease  such 
as  gonorrhea  which  has  always  been  concealed  as  a  secret  and 
shameful  thing,  are,  of  course,  in  their  infancy.  The  new  point  of 
view  toward  the  disease  as  a  public  health  problem  will  in  time 
lead  to  definite  understanding  of  its  prevalence. 

There  is  a  distinction  to  be  emphasized  between  the  number  of 
persons  who  have  active  gonorrhea  in  a  population  or  a  class  at  a 
given  time,  and  the  percentage  of  persons  who  have  had  it.  The 
statistics  are  modified  by  the  fact  that  since  gonorrhea  is  curable 
and  no  immunity  is  conferred  by  an  attack,  one  person  may  have  it 
a  number  of  times.     Another  element  of  inaccuracv  is  introduced 


30 

into  the  figures  by  tlie  ability  of  a  gonorrhea  to  remain  latent  for 
considerable  periods,  only  to  flare  up  like  a  new  attack  on  suitable 
provocation. 

Qonorrhea  in  Men. — Probably  the  highest  single  estimate  of  the 
prevalence  of  gonorrhea  is  that  of  Noeggerath,  which  was  made  be^ 
fore  the  discovery  of  the  germ  by  Neisser.  He  estimated  that  80 
per  cent  of  all  men  had  or  had  had  gonorrhea — figures  which  are  now 
generally  accepted  as  too  high.  Morrow,  and  Forcheimer,  on  the 
basis  of  a  large  experience  with  conditions  in  the  United  States,  pro- 
pose figures  varying  from  51  to  60  per  cent  of  the  adult  male  popula- 
tion as  having  had  the  disease.  Forcheimer  further  states  that  20 
per  cent  of  those  infected  have  acquired  the  disease  before  their 
twenty-first  year,  more  than  60  per  cent  before  their  twenty-fifth 
year,  and  more  than  80  per  cent  before  their  thirtieth  year  is  passed. 
Equally  large  estimates  are  given  by  various  well-informed  Euro- 
peans, notably  German  observers,  such  as  Blaschko,  Erb,  and  Pinkus. 
Getting  at  the  matter  indirectly,  figures  drawn  from  recent  army 
experience  indicate  that  gonorrhea  is  from  four  to  five  times  as 
prevalent  as  syphilis.  A  very  widely  accepted  conservative  estimate 
of  the  prevalence  of  syphilis  is  10  to  13  per  cent  of  the  adult  male 
population,  so  that  a  possible  prevalence  rate  for  gonorrhea  of  from 
40  to  60  per  cent  is  not  unreasonable.  Estimates  of  the  amount  of 
active  gonorrhea  acquired  by  a  large  group  of  men  in  a  given  time 
can  be  obtained  from  the  reports  of  the  Surgeon  General  of  the 
United  States  Army.  In  1907,  under  an  inadequate  system  of  ex- 
amination, the  admission  rate  (proportion  of  men  admitted  to  sick 
list)  for  gonorrhea,  was  about  12  to  13  per  cent  of  the  enlisted  per- 
sonnel. In  the  army  the  percentage  has  fallen  steadily  to  between  5 
and  6  per  cent  in  1915-16,  owing  to  the  efficiency  of  prophylactic  or 
preventative  methods  introduced  since  1911.  The  male  civil  popula- 
tion, which  is  not  protected  by  the  safeguards  that  surround  the 
army,  probably  has  a  prevalence  approaching  the  army  rates  during 
our  recent  mobilization.  Chronic  gonorrhea  often  escapes  inclusion 
in  statistical  estimates,  because  it  is  not  brought  to  the  attention  of 
physicians  or  medical  officers. 

Gonorrhea  in  Women. — Gonorrhea  is  estimated  to  be  sixteen  times 
as  prevalent  in  men  as  in  women  on  the  basis  of  statistics  which 
cannot,  however,  be  accepted  as  conclusive.  The  lowest  estimate 
quoted  and  one  Avhich  is  undoubtedly  too  low  is  probably  that  of 
Erb  who  maintained  a  number  of  years  ago,  that  only  5  per  cent  of 
four  hundred  women  whose  husbands  had  had  gonorrhea,  acquired 
Ihe  disease  themselves.  No  direct  estimates  of  value  exist,  relative 
to  prevalence  in  women,  but  an  indirect  conception  may  be  obtained 
from  the  fact  that  50  per  cent  of  absolute  and  one-child  sterility  is 


31 

due  to  gonorrhea  in  women.  The  percentage  of  gonorrhea  in  women 
varies  largely  with  their  social  status.  Among  the  most  refined 
types  of  unmarried  women  and  girls  it  is  probably  negligibly  small. 
Of  the  pregnant  women  in  the  public  hospitals  of  a  number  of  Con- 
tinental cities,  20  to  25  per  cent  were  said  to  have  had  gonorrhea. 
Prostitutes,  professional  or  occasional,  nearly  all  have  it.  The  esti- 
mated prevalence  of  the  disease  in  these  types  ranges  from  70  to  95 
per  cent,  as  determined  by  various  vice  investigations,  and  by  studies 
of  delinquent  women^  such  as  that  of  Haines,  who  found  percentages 
ranging  from  75.7  to  98.2  in  500  cases. 

It  must  be  more  than  apparent,  in  spite  of  the  obvious  difficulty  in 
interpreting  figures  which  contain  so  large  an  element  of  specula- 
tion, that  gonorrhea  offers  to  the  sanitarian  a  problem  of  the  first 
magnitude.  It  is  in  very  fact,  one  of  the  commonest  of  all  signifi- 
cant diseases.  It  wholly  outranks  the  large  majority  of  contagious 
infections  such  as  scarlet  fever,  smallpox  and  diphtheria,  and  even 
runs  a  close  second  to  measles,  the  most  contagious  disease  that 
affects  mankind. 


32 

CHAPTER  11. 
GONORRHEA  IN  MEN.    SYMPTOMS,  TESTS  FOR  INFECTIOUSNESS. 

For  convenience  gonorrkea  as  a  disease  may  be  described  as  it  ap- 
pears in  men,  in  women  and  in  children.  It  should  not  be  forgotten 
that  while  there  are  differences  between  the  three  types,  the  same 
principles  underlie  the  process  as  a  whole.  The  differences  are  more 
largely  due  to  differences  in  anatomical  structure  than  to  any  other 
factor. 

Acute  and  Chronic  Gonorrheal  Inflammation. — Gonorrhea  as  has 
been  pointed  out,  is  an  inflammation.  Like  every  disease  in  which 
inflammation  plays  an  important  part,  it  tends  to  pass  through  two 
stages — an  acute  or  active  early  stage  and  a  late,  slowly  progressive, 
inactive  or  chronic  stage.  If  the  acute  stage  of  the  inflammation  is 
sufficiently  violent,  that  is,  if  the  body  puts  up  a  big  enough  fight, 
the  germs  may  be  so  rapidly  destroyed  that  a  chronic  state  may  be 
avoided  altogether.  On  the  other  hand,  if  the  body  for  any  reason 
does  not  acutely  resent  the  invasion  or  if  something  is  lacking  in  its 
fighting  mechanism  or  again  if  something  is  done  to  weaken  its  de- 
fensive powers  during  the  acute  stage,  the  germs  are  not  killed  off 
but  manage  to  retain  a  foothold  for  a  long  time.  The  effect  of  their 
habitual  presence  is  in  a  certain  sense  to  make  the  body  tolerant  of 
or  indifferent  to  them.  It  may  grow  weary  of  the  fight,  so  to  speak, 
and  ceases  to  put  up  an  active  opposition.  There  is  also  perhaps,  a 
difference  between  individual  families  or  strains  of  the  gonococcus, 
in  the  matter  of  ability  to  adapt  themselves  to  the  conditions  which 
they  meet  in  their  host.  Precisely  as  an  invading  army  endeavors 
as  rapidly  as  possible  to  convert  the  strategy  of  war  into  the  strategy 
of  diplomacy  and  peaceful  infiltration,  so  a  really  clever  and  adapt- 
able germ  alters  its  tactics  enough  to  persuade  the  body  in  course 
.  of  time  to  put  up  with  the  inconvenience  of  its  presence.  With  this 
■process  of  getting  accustomed  the  infection  passes  from  an  acute  to 
a  chronic  phase.  If  the  germ  is  sufficiently  adaptable  this  chronic 
phase  soon  becomes  so  inconspicuous  that  the  patient  loses  sight  of 
it  altogether.  A  draw  or  truce  occurs  between  invader  and  invaded, 
which  is  by  no  means  a  victory  for  the  body  or  "cure."  Unless  some- 
thing happens  to  disturb  the  balance  of  the  draw  by  weakening  the 
body  or  stirring  up  the  germ  and  provoking  a  "flare-up,"  a  draw  or 
chronic  state  may  go  on  for  months,  or  even  several  years  before  the 
infection  dies  out.  On  the  other  hand,  it  should  not  be  supposed  for 
a  moment  that  the  germs  which  are  present  in  a  chronic  infection 
have  lost  their  power  to  spread  the  disease.  Many  persons  carry 
about  with  them  the  germs  of  pneumonia  in  the  nose  and  throat. 
Only  a  few,  however,  have  pneumonia  as  a  result.     In  the  same  way 


33 

in  the  clironic  phase  of  the  gonorrheal  inflammation,  many  persons 
may  carry  around  the  germs  in  their  genital  tracts  without  showing 
any  active  symptoms.  As  soon,  however,  as  the  germ  is  transferred 
from  a  person  in  whom  it  is  being  held  in  check  to  a  new  soil  in  a 
healthy  person,  it  promptly  sets  up  a  new  acute  process  fully  as  vio- 
lent as  that  which  originally  developed  in  the  carrier. 

The  Course  of  Acute  Gonorrhea  in  the  Male. — In  order  to  appreci- 
ate the  successive  possibilities  in  the  struggle  between  the  gonococ- 
cus  and  the  body  it  is  necessary  to  recall  the  anatomy  of  the  parts 
involved.  In  the  man  the  secretions  containing  the  germs  enter  the 
opening  through  which  the  urine  escapes  and  the  first  sign  of  the 
beginning  inflammation  appears  at  this  point  within  a  day  or  a  week 
after  they  have  gained  a  foothold.  The  symptoms  are  prickling  fol- 
lowed by  burning  in  the  urinary  canal  with  burning  and  pain  on 
urination.  There  is  considerable  redness  and  swelling  of  the  afifected 
parts  and  a  discharge  of  thick,  yellow  pus  from  the  urinary  canal. 
In  this  pus  enormous  numbers  of  the  gonococci  can  be  found.  The 
inflammation  progresses  backward  along  the  urinary  canal  and  in 
from  40  to  80  per  cent  of  the  cases  manages  to  travel  back  the  entire 
length  of  the  canal  into  what  is  called  the  posterior  urethra.  The 
condition  is  then  spoken  of  as  a  "posterior"  gonorrhea. 

Posterior  Gonorrhea  and  the  Genital  Complications. — Posterior 
gonorrhea  is  a  highly-  undesirable  complication  of  the  disease. 
When  the  inflammation  extends  this  far,  new  and  very  painful  symp- 
toms usually  develop.  Furthermore,  into  the  deeper  part  of  the 
urinary  canal  near  the  base  of  the  bladder  open  the  canals  which 
lead  from  the  reproductive  organsT'Tr in  a  "posterior  gonorrhea" 
for  any  reason  the  germ  succeeds  in  traveling  downward  through 
these  canals  leading  into  the  epididymis,  a  structure  connected  with 
the  testicle,  in  which  the  male  cells  mature,  it  has  done  more  than 
merely  invade  the  man's  tissues.  It  has  invaded  his  future  and  his 
personal  immortality.  The  inflammatory  process  which  then  de- 
velops, if  it  involves  both  testicles  or  their  appendages,  while  it  may 
not  cost  him  his  sexual  powers,  will  be  likely,  then  and  there  to  de- 
stroy his  power  to  father  a  child.  When  the  inflammatory  process 
which  is  evidenced  by  swelling  and  pain  in  the  testicles,  dies  out  or 
becomes  quiescent,  the  man  may  never  think  of  it  again.  In  the 
later  years  of  his  life  he  wonders,  not  always  with  good  grace,  why 
his  healthy  wife  has  no  children,  as  he  listens  to  the  clatter  of  the 
shoe  heels  of  adopted  youngsters  on  his  stairs.  Sterility  is  by  no 
means  a  feminine  monopoly  and  is  only  too  often  the  heritage  of 
masculine  "posterior  gonorrhea." 

Causes  and  Complications  of  Chronic  or  Persistent  Gonorrhea.— 
To  describe  all  the  symptoms  of  acute  gonorrhea  in  the  male  would 


34 

crowd  out  other  considerations  of  greater  importance  here.  The 
average  duration  of  the  acute  phase  of  the  infection  is  about  eight  to 
twelve  weeks.  The  discharge  and  active  inflammatory  sj^mptoms 
and  the  burning  on  urination  graduall}^  subside.  The  painful  erec- 
tions, commonly  known  as  chordee,  also  disappear.  If,  however,  the 
smooth  progress  of  the  case  has  been  interfered  with  by  the  patient's 
disobeying  instructions  or  through  his  attempt  to  treat  himself,  or 
again,  through  the  ministrations  of  an  inexperienced  or  unskilled 
medical  adviser,  the  acute  phase  results  not  in  recovery  but  in 
chronic  or  persistent  gonorrhea.  In  spite  of  the  best  possible  care 
a  small  percentage  of  acute  cases  will  become  chronic.  It  is  ex- 
ceedingly important,  however,  since  there  are  so  many  seemingly 
discouraging  features  about  the  entire  situation  with  respect  to 
gonorrhea,  to  emphasize  here  and  again,  the  very  favorable  outlook 
for  complete  cure  in  the  large  majority  of  intelligently  managed 
cases  of  gonorrhea.  Complications  and  chronicity  with  delay  in  cure 
and  prolonged  infectiousness  are  not  the  fate  of  every  patient  who 
acquires  the  disease.  They  are  the  penalty  of  negligence,  ignorance, 
and  indifference  in  the  overwhelming  proportion  of  cases.  The  out- 
look in  the  treatment  of  the  disease  can  be  brightened  in  exactly  the 
proportion  that  these  unfavorable  factors  can  be  eliminated  by  rais- 
ing the  standard  of  public  comprehension,  by  developing  the  per- 
sonal cooperation  of  the  patient,  and  by  contributing  to  the  efficiency 
of  medical  care. 

Stricture. — A  chronic  posterior  gonorrhea  is  an  unfortunate  com- 
plication from  the  standpoint  of  the  man's  future  and  of  the  public 
liealth.  If  the  inflammation  in  the  urinary  canal  itself  persists, 
small  ulcers  are  apt  to  form  and  these  in  turn  on  healing  leave 
scars  which  shrink,  reducing  the  diameter  of  the  canal.  Such  a  con- 
dition is  called  stricture.  A  stricture  interferes  with  the  passage  of 
urine  and  predisposes  the  patient  to  complications  attendant  upon 
the  infection  of  his  bladder  by  other  germs,  and  the  passage  of  that 
infection  upward  through  the  duct  which  leads  from  the  kidney  to 
the  bladder  wdth  resulting  infection  of  the  kidney.  The  last  men- 
tioned complication  is,  however,  unusual.  Prompt  treatment  as 
soon  as  any  obstruction  in  the  stream  develops  will  prevent  any 
complications. 

Relapses  mid  Flare-ups;  ''Gleet"  or  ''Morning  Drop." — In  most 
chronic  posterior  gonorrhea  active  inflammation  disappears,  and 
the  patient  may  believe  he  is  Avell.  From  time  to  time,  however, 
usually  under  the  influence  of  alcohol  or  sexual  indulgence,  there 
may  be  a  flare-up  and  a  fresh  discharge  of  pus  of  briefer  duration 
than  the  original  attack.  This  the  patient  may  mistake  for  a  new 
infection,  easily  cured.     The  continuity  of  the  process  between  flare- 


35 

ups  is,  however,  evidenced  by  tiie  persistence  of  a  very  slight  dis- 
charge in  the  form  of  a  drop  or  two  of  a  sticky  fluid  which  appears 
at  the  urinary  opening  usually  in  the  morning  on  arising.  This  is 
the  condition  commonly  known  as  gleet,  or  "morning  drop,"  and  in 
this  drop  of  discharge  which  the  French  have  sardonically  chris- 
tened "la  goutte  militaire,"  gonococci  can  usually  be  found.  Gon- 
orrhea in  this  stage  is  not  one  whit  less  dangerous  to  others  than 
is  the  acute  infection.  In  fact,  it  is  vastly  more  dangerous  because 
when  the  patient  reaches  this  stage  he  usually  discards  the  restraints 
as  to  sexual  indulgence  which  have  been  put  upon  him  by  the  phy- 
sician, with  the  result  that  he  promptly  infects  his  partner  if  she  be 
not  already  infected.  In  the  sociology  of  the  disease  "gleet"  is  its 
most  important  stage. 

Chronic  Gonorrhea  of  the  Prostate  and  Urethral  Glands. — The 
factors  which  make  a  chronic  gonorrhea  of  the  type  described  an 
obstinate  and  serious  affair  are  easily  understood.  The  urinary 
canal  or  urethra  is  lined  with  innumerable  tubular  mucous  glands 
and  pockets.  Once  the  gonococci  have  invaded  them  in  the  march 
of  the  acute  infection  upward  and  backward  througli  the  canal  and 
have  gained  the  truce  which  chronicity  represents,  every  'resource 
in  treatment  may  fail  to  dislodge  them.  The  only  outlook  may  be 
for  them  to  die  out  of  themselves,  although  modern  methods  with 
the  use  of  instruments  offer  a  better  outlook  than  formerly.  The 
prostate  gland,  a  large  gland  which  surrounds  the  posterior  urethra 
at  the  point  where  it  passes  into  the  bladder,  and  which  is  prac- 
tically always  involved  in  posterior  gonorrhea,  has  a  structure 
which  makes  it  a  stronghold  for  the  gonococcus  in  chronic  cases. 
Chronic  infection  of  the  prostate  gland  often  keeps  the  victim  under 
the  weather  for  long  periods  and  threatens  him  while  it  persists, 
with  the  risk  of  having  the  gonorrheal  infection  spread  through 
his  blood  to  his  joints  (rheumatism)  and  other  parts  of  the  body. 
The  discharge  from  both  of  these  types  of  glands  forms  a  part  of 
the  semen  and  thus  maintains  for  long  periods  the  risk  of  infection 
in  sexual  intercourse. 

Tests  for  Chronic  Urethritis,  etc. — Chronic  inflammation  of  the 
urethra  may  finally  pass  into  a  state  in  Avhich  it  is  apparently 
innocuous  so  far  as  the  transmission  of  gonorrhea  is  concerned. 
It  is,  however,  a  difficult  matter  to  tell  a  patient  when  such  a  con- 
dition is  reached.  The  examination  of  a  patient  with  chronic  ure- 
thritis for  evidence  of  a  persistent  gonorrheal  infection  involves 
not  only  the  microscopic  examination  of  the  gleety  discharge  for 
gonococci,  but  also  an  examination  of  the  secretions  of  the  prostate 
gland,  which  may  harbor  the  germs  after  they  have  disappeared 
from  the  rest  of  the  tract.     This  is  accomplished  by  staining  and 


36 

examining  the  shreds  which,  appear  in  the  urine  in  cases  of  inflam- 
mation of  the  prostate.  In  some  cases  it  may  be  desirable  to 
massage  the  prostate  gland  with  the  finger  through  the  rectum, 
and  examine  the  urine  after  the  discharge  or  secretion  has  been 
forced  out  into  the  urinary  canal  in  this  way. 

In  order  to  determine  whether  a  persistent  discharge  is  due  to 
gonococcus  infection  or  whether  a  gonorrhea  is  cured  or  not,  it  may 
be  necessary  to  excite  a  fresh  discharge  by  irritation  of  the  urinary 
canal  by  the  injection  of  a  strong  solution,  or  otherwise.  This  new 
discharge  will  contain  cells  from  the  glands  and  mucous  membrane 
of  the  urinary  canal.  In  these  cells  the  gonococci  can  be  found 
by  the  microscope  if  they  are  the  cause  of  the  persistent  discharge, 
or  if  the  case  is  not  cured. 

MorMd  Fear  of  Gonorrhea. — The  ''morning  drop"  and  "clap 
threads"  in  the  urine,  while,  of  course,  of  superlative  importance 
in  the  proper  estimation  of  the  condition  of  a  man  who  has  had 
gonorrhea,  occasionally  furnish  a  nervous  person  with  a  cause  for 
morbid  worry  which  is  out  of  proportion  to  their  significance  in 
his  particular  case.  The  wise  course  for  a  patient  who  is  inclined 
to  worry  about  floating  objects  or  stringy  mucus  in  his  ur-ine, 
or  a  drop  of  discharge  at  the  urinary  opening  in  the  morning, 
whether  or  not  he  has  had  gonorrhea,  is  to  proceed  to  the  very 
best  specialist  available,  and  place  himself  unreservedly  in  his 
hands  and  accept  his  assurances  as  final. 

Gonorrheal  Nervous  Prostrations. — Gonorrhea,  perhaps  because 
it  involves  structures  so  intimately  associated  with  the  nervous 
system  and  so  richly  supplied  with  nerves,  gives  rise  to  a  peculiar 
mental  and  physical  depression  in  from  5  to  10  per  cent  of  its 
victims,  a  post-gonorrheal  nervous  prostration  or  neurasthenia, 
which  drives  them  from  pillar  to  post,  seeking  relief  for  weakness, 
vague  pains,  and  inability  to  gather  themselves  together  or  to 
work.  These  symptoms  are  to  be  regarded  essentially  as  after 
effects,  and  not  as  evidence  that  the  gonococcus  is  undermining 
tlie  patient's  manhood. 


37 

CHAPTER  III. 

SYSTEMIC  GONORRHEA  AND  GONORRHEA  IN  WOMEN  AND 

CHILDREN. 

Gonorrhea  in  women  is  the  most  embittering  and  tragic  aspect 
of  the  disease.  The  overwhelming  proportion  of  infections  are 
innocent.  A  man  has  a  chance,  at  least,  to  know  what  ails  him. 
The  woman,  in  the  existing  state  of  popular  and  even  medical 
sentiment,  is  lied  to  at  every  turn  of  the  way.  Gonorrhea  is  a 
serious  enough  disease  in  men ;  in  women  it  may  be  a  disaster. 
Gonorrhea  is  usually  cured  in  men.  In  women,  while  the  disease 
if  taken  in  time  is  curable,  the  problem  is  much  more  difficult.  In 
women  in  general  gonorrhea  may  run,  on  the  one  hand,  a  course 
so  mild  that  although  virulently  infectious,  the  woman  may  never 
realize  she  has  the  disease;  on  the  other  hand,  it  may  reduce  her 
almost  at  once  to  a  pitiable  invalidism,  or  cost  her  her  life. 

Reasons  for  the  Greater  Seriousness  of  Gonorrhea  in  Women. — 
The  greater  seriousness  and  obstinacy  of  gonorrhea  in  women  is 
explainable  on  comparatively  simple  anatomical  and  physiological 
grounds.  The  woman's  urinary  system  is  simpler  than  the  man's, 
so  that  the  full  force  of  the  infection  is  rarely  felt  here.  Inflam- 
mation of  the  urethra  and  bladder  may  occur  and  are  usually 
attributed  to  a  "cold."  The  usual  rule,  however,  is  for  it  to  fall 
with  full  force  upon  her  sexual  organs.  The  man's  sexual  organs 
are  largely  on  the  outside,  so  to  speak — that  is,  outside  the  abdomi- 
nal cavity.  The  woman's,  while  theoretically  outside,  open  into 
the  abdominal  cavity  at  the  mouth  of  the  tube  that  carries  the 
eggs  from  the  ovary  into  the  womb.  A  discharge  of  infected  semen 
thus  carries  the  enemy  to  her  very  vitals.  It  should  be  realized, 
however,  in  describing  the  complications  of  gonorrhea  in  women, 
that  by  no  means  every  woman  who  is  infected  progresses  step  by 
step  to  the  worst  possible  outcome.  It  is  a  notable  fact  that  many 
women  who  acquire  the  disease  have  so  few  symptoms  from  it  that 
they  never  realize  that  they  are  infected  and  do  not  seek  medical 
advice.  The  condition  may  only  be  recognized  incidentally  in  the 
course  of  other  examinations.  Such  cases  are  a  public  health 
problem  rather  than  a  personal  medical  one.  Not  every  case  of 
gonorrheal  infection  in  a  woman  results  in  sterility,  or  necessitates 
radical  operations.  On  the  other  hand,  there  can  be  nothing  gained 
by  attempting  to  gloss  over  the  dark  side  of  the  situation.  While 
one  may  rejoice  that  many  escape  the  worst,  it  is  impossible  to 
ignore  the  fact  that  enough  women  are  wrecked  by  gonorrhea  in 
one  way  or  another  to  maintain  an  entire  specialty  in  medicine — 
gynecology,  which  would  become  relatively  a  side  issue  in  surgery 


38 

if  the  effects  of  gonorrheal  pelvic  inflammation  and  of  abortion  or 
miscarriage  could  be  eliminated.  Few  have  been  found  to  dispute 
the  opinion  of  Jsfoeggerath,  who  first  recognized  gonorrhea  in 
women  as  a  definite  and  distinct  condition,  when  he  stated  that 
80  to  90  per  cent  of  pelvic  inflammatory  disease  and  50  per  cent 
of  absolute  and  one-child  sterility  in  women  is  due  to  gonorrhea. 

Course  of  Gonorrheal  Injection  in  Women. — The  successive  stages 
and  possibilities  in  a  gonorrheal  infection  in  the  woman  may  be 
described  as  follows,  always  bearing  in  mind  the  fact  that  the 
process  may  stop  so  far  as  the  patient  is  concerned,  at  any  of  the 
stages  mentioned,  and  become  arrested  or  chronic  or  may  even  die 
out  of  itself.  It  is  the  tremendous  uncertainty  attaching  to  the 
course  of  the  disease  and  its  outcome  that  makes  it  so  important  to 
understand  all  its  activities. 

In  a  variable  percentage  of  cases  the  first  symptoms  may  be  from 
the  urinary  canal  and  bladder,  as  in  men,  but  usually  less  severe. 
Not  infrequently  an  abscess  may  form  in  a  gland  at  the  opening 
of  the  vagina. 

When  the  gonococci  in  their  ascent  gain  entrance  to  the  genital 
tract  and  infect  the  neck  of  the  womb  (cervix),  a  discharge  of 
mucous  and  pus  from  the  vagina  occurs,  which  is  usually  called 
leucorrhea  or  ''whites."  It  should  be  emphatically  stated,  how- 
ever, that  not  all  leucorrhea  is  due  to  gonorrhea.  In  many  cases, 
with  the  first  menstrual  period  after  infection,  gonorrhea  of  the  neck 
of  the  womb  or  the  vagina  is  likely  to  be  followed  by  infection 
of  the  womb  itself,  and  then  of  one  or  both  of  the  tubes  that  lead 
from  the  ovary  to  the  womb.  These  tubes  open,  as  has  been  said, 
into  the  abdominal  cavit3^  A  gonorrheal  inflammation  of  a  tube 
gives  rise  to  symptoms  suggesting  an  attack  of  appendicitis, 
although,  of  course,  it  may  occur  on  the  left  as  well  as  on  the  right 
side.  Tubal  inflammation  usually  results  in  the  closure  of  the 
abdominal  opening  if  both  tubes  are  affected  so  that  eggs  can  no 
longer  pass  down  to  the  womb,  and  the  woman  becomes  sterile. 
If  both  ends  of  either  tube  are  closed,  pus  usually  collects,  forming 
a  "pus  tube,"  which  may  become  chronic  without  rupturing,  and 
usually  has  to  be  removed  by  operation.  In  severe  gonorrheal 
infections  all  the  steps  described  above  may  occur  in  rapid  suc- 
cession and  the  inflammation  may  then  extend  from  the  abdominal 
opening  of  the  tube  into  the  abdomen  itself.  The  woman  thereupon 
develops  what  is  called  peritonitis,  an  inflammation  of  the  lining 
membrane  of  the  abdominal  cavity,  a  complication  of  the  utmost 
gravity  and  occasionally  fatal  in  its  outcome. 

Gonorrhea  and  Pregnancy. — For  the  woman  with  gonorrhea, 
pregnpncy  greatly  increases  the  risk  of  a  spread  of  her  infection 


39 

and  an  exaggeration  of  all  its  manifestations.  If  the  tubes  carry- 
ing the  egg  to  the  womb  have  been  distorted  by  a  gonorrheal  inflam- 
mation, bnt  not  closed,  the  fertilized  egg  may  be  caught  in  a  pocket 
without  reaching  the  womb,  and  the  woman  thus  develops  the 
child  in  the  tube  or  the  abdominal  cavitj^  Such  an  accident  may, 
of  course,  result  at  times  from  non-gonorrheal  changes  in  the  tubes. 
Tubal  or  extra-uterine  pregnancy,  so-called,  may,  if  not  quickly 
recognized  and  operated  upon,  result  in  the  death  of  the  mother 
from  internal  hemorrhage  following  rupture  of  the  pregnant  tube. 
If  by  any  chance  the  child  develops  far  enough,  the  condition  of 
the  organs  in  the  abdominal  cavity  baffles  description,  and  opera- 
tive interference  has  little  prospect  of  success.  Any  woman  who 
notices  that  she  continues  to  bleed  after  she  believes  herself  preg- 
nant, either  irregularly  or  at  the  time  when  her  menstrual  periods 
would  ordinarily  be  due,  ought  to  have  a  thorough  examination 
for  the  possibility  of  tubal  pregnancy. 

,  Gonorrheal  Child-Bed  Fever  and  Sterility. — In  a  woman  with 
an  acute,  active  gonorrhea  whose  tubes  and  womb  are  still  normal, 
so  that  she  can  become  normally  pregnant,  the  delivery  of  the 
child  opens  the  way  to  some  of  the  most  disastrous  complications 
of  the  disease.  After  the  passage  of  the  child  the  womb  is  literally 
raw  and  bleeding,  and  the  way  is  open  (for  infection  to  get  a  start) 
through  the  lowered  resistance  of  the  tissues,  which  is  impossible 
under  normal  conditions.  The  gonococci  in  the  neck  of  the  womb 
seize  the  opportunity,  in  company  with  other  germs,  to  make  a 
whirlwind  charge,  and  within  a  few  days,  or,  perhaps,  a  few  hours, 
the  mother  may  be  dead  of  "child-bed  fever."  While  not  all  such 
patients  die,  those  who  survive  are  likely  to  be  hobbling,  pain- 
wracked  cripples  until  a  radical  operation  relieves  them  of  all 
the  damaged  structures.  Pregnancy  in  a  woman  with  chronic,  as 
distinguished  from  acute  gonorrhea,  is  one  of  the  chief  predisposing 
causes  of  inflammation  of  the  tubes  and  subsequent  sterility.  The 
pregnancy  gives  the  woman  a  chance  to  have  one  child,  but  she  never 
has  another.  This  constitutes  the  so-called  one-child  sterility 
already  referred  to.  That  not  all  one-child  sterility  is  due  to 
gonorrhea  must  be  borne  in  mind  by  critical  inspectors  of  genea- 
logical trees. 

'^'Pelvic  Inflammatory  Disease.-" — Pelvic  inflammatory  disease  is 
a  general  term  employed  to  describe  the  condition  following  an 
extension  of  a  gonorrhea  from  the  more  external  female  parts 
upward  into  the  structures  of  the  lower  abdomen.  Pus  tubes,  for 
example,  are  a  phase  of  pelvic  inflammatory  disease.  ^  If  the  germ 
escapes  through  the  wall  of  inflammation  thrown  up  by  the  body 
against  it,  and  gets  into  the  surrounding  tissues,  everj^  part  and 


40 

structure  in  the  neigliborliood  are  involved  in  the  fight,  and  intes- 
tines, omentum,  and  womb  are  matted  together  around  an  abscess 
that  may  later  burst  or  be  opened  through  the  genital  canal 
(vagina)  or  even  the  rectum.  The  treatment  in  cases  of  this  type 
must  often  be  the  operation  euphoniously  called  "hysterectomy  plus 
bilateral  salpingo-oophorectomy"  or  "pan-hysterectomy."  After  it 
the  woman  is  usually  told  that  a  piece  of  one  ovary  was  left  (as  it 
often  is)  so  that  she  can  still  feel  she  is  a  woman,  since  that  is 
all  the  evidence  of  the  fact  that  she  will  ever  have  from  that  time 
on,  except  that  she  will  continue  to  wear  skirts.  For  the  benefit  of 
her  husband  they  leave  her  a  vagina;  for  the  benefit  of  herself, 
perhaps,  a  piece  of  ovary.  To  hear  such  a  woman,  so  defenceless- 
looking  in  her  braided  hair  and  ether  jacket,  whisper  timidly  as 
they  wheel  her,  uncomplaining,  up  to  the  operating  table:  "I  do 
hope  they'll  fix  me  so  I  can  have  a  baby" ;  to  see  the  skin  and 
muscles  gape  before  the  sweep  of  the  knife  ,^  to  think  that  woman's 
thoughts  for  her,  through  an  hour  of  ether  haz6  and  hushed  com- 
ment and  the  peculiar  sibilant  click  of  hemostats  as  the  surgeon 
does  his  uttermost  to  cobble  up  the  wreckage  and  save  her  hope; 
finally  in  despair  he  begins  the  quick  swinging  practiced  move- 
ments that  mean  it  all  must  go;  and  then  to  see  her  again  a  week 
later,  after  they  have  told  her  the  ovary  story,  is  an  experience 
to  make  the  hardest  turn  away  his  face. 

Concealed  or  Latent  Gonorrhea  in  Certain  Glands. — Gonorrhea, 
regardless  almost  of  the  part  of  the  genital  tract  in  which  the 
germ  is  deposited,  seldom  fails  to  invade  certain  glands,  called 
Bartholin's  and  Skene's  glands,  which  lie  at  the  entrance  of  the 
vagina,  and  correspond  to  certain  deep  glands  lying  beside  the 
male  urethra.  Few  women  whose  married  life  begins  with  an 
abscess  at  the  opening  of  the  genital  canal  are  told  they  have  gonor- 
rhea, although  this  is  one  of  its  characteristic  beginnings.  In  these 
glands,  even  if  abscesses  do  not  form,  the  gonococcus  may  remain 
latent  for  long  periods.  The  secretion  from  them  is  discharged 
upon  the  mucous  membrane  of  the  vaginal  opening  before  and 
during  intercourse,  and  though  there  may  not  be  a  living  gonococ- 
cus in  the  canal,  the  woman  may  be  free  from  leucorrheal  discharge, 
and  in  all  other  respects  seem  healthy,  there  will  be  gonococci 
enough  here  to  infect  an  army.  An  examination  for  gonorrhea 
in  the  woman  which  fails  to  include,  besides  a  microscopic  study 
of  a  smear  from  the  urinary  canal  and  the  neck  of  the  womb 
(cervix),  smears  from  Bartholin's  glands,  overlooks  entirely  one 
of  the  strongholds  of  the  infection. 

Systemic  Gonorrhea,  Rheumatism,  etc. — The  description  of  gonor- 
rhea in  both  men  and  women  has  thus  far  been  that  of  a  genital 


41 

infection.  The  invasion  of  the  body  as  a  whole  by  the  gonococcus 
may  be  said  to  be  rare,  but  serious.  About  one  case  in  a  hundred 
is  thus  affected  and  men  more  often  than  women.  While  the  iris 
of  the  eye,  the  heart,  the  slcin,  the  nervous  system  and  other  struc- 
tures may  be  affected,  these  accidents  are  rare.  The  commonest 
systemic  complication  is  involvement  of  the  joints  in  the  form  of 
gonorrheal  rheumatism.  Gonorrheal  rheumatism  is  a  chronic  and 
resistant  disease  which  sometimes,  although  not  usually,  produces 
permanent  crippling.  Though  it  may  come  on  early  in  the  infec- 
tion, many  cases  are  due  especially  in  men  to  the  persistence  of  the 
disease  in  such  structures  as  the  prostate  gland  and  the  seminal 
vesicles,  from  which  the  germs  escape  into  the  blood,  to  be  carried 
to  other  parts  of  the  body. 

Gonorrhea  of  the  Eye  {Gonorrheal  Ophthalmia). — Under  this 
head  is  included  the  form  of  gonorrhea  of  the  eye  already  spoken 
of  as  gonorrheal  ophthalmia,  which  while  it  can  and  does  occur  in 
adults,  is  overwhelmingly  more  common  in  children.  The  very  first 
word  that  should  be  said  about  gonorrhea  of  the  eye  is  that  it  can 
be  prevented.  The  next  word  is,  that  if  not  prevented,  it  will 
probably  cause  blindness.  Increasing  knowledge  of  the  first  fact 
lias  diminished  but  by  no  means  done  away  with  the  importance 
of  the  second.  Gonorrheal  ophthalmia  is  a  disease  of  the  inno- 
cents. The  usual  time  of  infection  is  in  the  passage  of  the  child 
down  the  infected  birth-canal  of  the  mother.  The  bare  thought  of 
a  little  chubby  child's  bright  eyes  being  ground  through  the  filthy 
pus  of  a  "clap"  sickens  a  decent  man.  Yet  this  is  exactly  what 
happens,  and  its  mother,  all  unknowing,  is  made  the  doer  of  it. 
Usually  within  twenty-four  hours  after  birth,  if  a  preventative  has 
not  been  used,  pus  begins  to  form  in  the  eyes,  and  with  almost 
lightning-like  rapidity  the  clear,  bright  cornea  of  the  eye  ulcerates, 
under  the  swollen,  pus-filled  lids,  breaks  through,  and  lens  and 
all  collapse  into  the  opening.  When  the  process  subsides,  the 
baby  is  blind.  The  mere  statement  that  one-third  of  the  blindness 
in  asylums  and  one-half  the  blindness  dating  from  birth  is  due  to 
gonorrhea  of  the  eye  conveys  no  impression  whatever  of  the  tragedy. 
One  has  to  see  one  of  these  little  children,  rocking  back  and  forth 
in  a  railed-in  chair,  waving  its  hand  between  face  and  window  be- 
cause that  flickering  of  the  finger  shadows  across  the  twilight  is 
all  it  will  ever  know  of  more  than  half  of  life,  one  has  to  see  this 
thing,  and  watch  the  baby  groping  about  on  the  fioor  and  gurgling 
as  it  feels  of  your  shoe-strings,  really  to  know  in  the  soul  of  him, 
what  gonorrhea  means. 

Prevention  of  Gonorrheal  Blindness. — The  prevention  of  gon- 
orrhea of  the  eye  is  accomplished  by  tlie  use  of  a  I  per  cent  solu- 


42 

tion  of  silver  nitrate,  which  is  dropped  into  the  eyes  immediately 
after  birth.  In  the  vast  majority  of  civilized  countries  this  is  now 
a  universal  and  legally  compulsory  practice.  It  is  required  by 
most  of  our  states,  and  it  should  be  done  on  every  baby  born  into 
the  world,  no  matter  what  its  parentage.  The  necessary  medicine 
and  directions  for  carrying  out  this  protective  measure  can  be  ob- 
tained from  any  state  board  of  health.  The  universal  observance 
of  this  preventive  measure  will  in  time  banish  from  the  earth  the 
gonorrheal  blindness  that  begins  in  infancy. 

A  certain  amount  of  ocular  gonorrhea  is  due  to  accidental  inocu- 
lations and  to  carelessness,  and  for  this  reason  the  care  of  the  eyes 
is  the  first  thing  in  regard  to  which  a  physician  instructs  his  gon- 
orrheal patient.  Gonorrheal  blindness  may  of  course  occur  in  chil- 
dren after  birth,  as  a  result  of  their  becoming  infected  by  handker- 
chiefs and  articles  of  personal  use  from  adults  who  have  the  dis- 
ease. Special  precautions  about  nurse  maids,  and  in  hospitals, 
about  visitors,  are  essential.  Sometimes  in  the  form  of  gonorrhea 
known  as  vulvovaginitis,  described  below,  the  child  may  infect  its 
ejes  from  its  own  discharges.  Such  complications  are  especially 
likely  to  occcur  under  conditions  of  crowding  and  bad  hygiene.  If 
treatment  of  gonorrhea  of  the  eye  is  begun  immediately  after  its 
onset  and  is  expertly  carried  out  in  a  hospital  by  skilled  doctors 
and  nurses,  it  may  be  prevented  from  going  on  to  total  blindness. 

Gonorrheal  Inflammation  of  the  Genitals  in  Girl  Children, — Gon- 
orrheal vulvo-vaginitis  is  an  elaborate  Latin  and  Greek  name  for 
the  most  pathetic  of  all  the  tragedies  to  which  woman-kind  is  sub- 
jected by  this  disease.  Little  girl  children  for  some  reason  are 
extremely  susceptible  to  the  gonococcus.  If  it  is  deposited  upon 
the  external  genitals  from  the  fingers  of  a  nurse,  from  a  soiled  or 
infected  diaper,  from  an  infected  toilet  seat  or  bed-pan,  or  in  the 
passage  of  the  child  through  its  mother's  birth-canal,  it  sets  up  im- 
mediately a  gonorrheal  inflammation  which,  however,  rarely  extends 
up  the  genital  tract  as  in  an  adult  woman.  Its  usual  duration  even 
under  skilled  treatment  is  years  instead  of  months.  No  child  hav- 
ing it  should  be  allowed  to  leave  an  isolation  hospital,  for  it  is  ex- 
tremely contagious.  It  spells  the  end  of  the  child's  education  un- 
less there  happen  to  be  special  classes  held  for  such  cases,  as  in 
Fome  of  the  larger  hospitals,  since  no  child  with  it  should  be  in 
school.  It  may  mean  the  same  thing  for  their  life  work,  for  their 
health  and  for  their  hopes  of  having  children,  that  it  does  for  their 
mothers. 

Vulvo-vaginitis  in  Hospitals. — Gonorrheal  vulvovaginitis  is  a 
scourge  of  infant  hospitals,  and  asylums,  and  also  of  all  places 
where  children  are  crowded  into  close  and  undiscriminating  con- 


43 

tact  with  adults,  as  when  they  sleep  in  the  same  beds  with  them, 
for  example.  So  dangerous  is  it  that  no  well-regulated  public  hos- 
pital admits  any  child,  regardless  of  its  antecedents,  to  a  children's 
ward,  without  a  smear  of  the  genital  secretions.  Conversely  the 
appearance  of  gonorrheal  vulvo-vaginitis  on  a  hospital  ward  is  a 
reflection  on  someone,  and  should  cause  the  physician  and  the  nurses 
in  charge  many  painful  hours  of  self -inquiry.  No  better  example 
of  the  savage  heartlessness  of  the  type  of  human  being  to  whom 
'Venereal"  disease  is  outside  the  pale  of  consideration,  can  be 
imagined,  than  that  furnished  by  an  instance  in  which  several  little 
girls  with  hereditary  syphilis  in  one  of  the  largest  charity  hospitals 
in  this  country  were  knowingly  placed  on  a  ward  with  vulvo-vaginitis 
cases  because  gonorrhea  and  syphilis  are  both  "venereal"  diseases. 
In  spite  of  the  protests  of  the  physician  the  little  syphilitic  girls 
who  had  had  some  chance  for  recovery  from  the  syphilis,  were  ruined 
as  effectually  as  if  they  had  been  raped,  by  being  made  to  add  the 
vulvo-vaginitis  to  their  woes.  The  eccentricities  of  "Kultur"  have 
indeed  little  to  offer  us  that  is  not  already  in  our  midst,  in  the  per- 
sons, the  methods  and  the  ideals  of  those  who  place  the  victims  of 
'Venereal  diseases"  outside  the  dictates  of  mercy  and  justice,  be- 
cause their  ailments  are  "punishments  for  sin  and  badges  of  dis- 
grace." 


44 

CHAPTER  IV. 
TREATMENT  AND  HYGIENE  OF  GONORRHEA. 

The  Difficulties  of  Treatment. — The  treatment  of  gonorrhea  bears 
the  earmarks  unfortunately  familiar  in  more  than  one  field  of  medi- 
cal practice,  in  that  manj^  methods  and  a  host  of  remedies  mean 
doubtful  ground.  Nearly  every  expert  in  the  management  of  the 
disease  has  his  own  peculiar  way  of  going  about  it.  General 
principles  are  recognized,  to  be  sure,  but  they  lack  sv)ecificity,  as 
we  say.  That  is,  no  one  or  two  remedies  or  methods  can  be  certain 
of  producing  results  in  the  overwhelming  proportion  of  patients 
as  is  the  case  for  example,  in  syphilis.  No  epoch-making  achieve- 
ments in  the  treatment  of  gonorrhea  seem  to  have  been  recorded  in 
recent  years,  although  on  the  whole  there  has  been  a  persistent 
improvement  in  methods  and  results.  The  growing  appreciation 
of  the  importance  of  the  microscope  in  the- control  of  treatment  is  a 
signal  advance.  At  times  it  seems  as  if  the  rather  sordid  peculiari- 
ties of  the  disease,  the  difficulty  of  getting  the  patient's  cooperation 
when  it  is  so  vital  to  a  successful  issue,  the  lack  of  the  spectacular, 
the  tendency  to  obstinacy  and  chronicity,  and  the  brilliant  triumphs 
in  the  related  field  of  syphilis  had,  in  an  indefinite  way,  deflected 
interest  from  a  field  in  which  compensations  are  few  and  the  labor 
often  out  of  proportion  to  the  rewards.  Yet  nothing  is  becoming 
more  apparent  thru  that  intelligent  treatment  of  a  gonorrhea  is 
an  essential  to  its  cure,  and  should  be  adequately  provided  for  in 
the  interest  of  the  public  health  alone,  to  say  nothing  of  the  patient 
himself.  It  rests  with  the  future  to  devise  means  to  bring  home  the 
importance  of  adequate  care  of  gonorrhea  and  a  more  pressing 
sense  of  responsibility  in  regard  to  it,  first  to  the  public,  and  then 
perhaps  to  the  medical  profession. 

Local  and  General  Measures  Emploijed. — In  general  an  acute 
gonorrhea  is  approached  by  the  use  of  local  injections  of  various 
drugs  into  the  infected  canal,  and'in  gonorrhea  of  the  urinary  tract 
by  the  administration  of  medicines  by  mouth  which  when  excreted 
by  the  kidneys  and  passed  out  through  the  urine,  have  a  favorable 
influence  upon  the  structures  involved.  Preparations  containing 
silver  have  a  long  established  reputation  for  local  use.  The  action 
of  many  of  the  drugs  is  less  that  of  a  means  of  killing  the  gonococ- 
cus  than  a  means  of  making  the  soil  unfavorable  for  it.  In  addi- 
tion to  this  active  medication,  the  diet  of  the  patient  calls  for  care- 
ful regulation,  sexual  excitement  must  imperatively  be  avoided,  rest 
is  usually  essential  for  a  time  while  the  process  is  at  its  height,  and 
alcohol,  always  particularly  vicious  in  its  effect  on  acute  gonorrhea, 
must  be  absolutely  abstained  from. 


45 

The  Patient's  Coo^ieration. —  Ll  is  one  of  the  struggles  ol'  tlie 
physician  who  treats  gonorrhea  to  secure  from  his  patient  by  a 
combination  of  cajolery  and  threats,  the  unquestioning,  prolonged 
obedience  to  orders  which  the  cure  of  a  gonorrhea  requires.  In 
fact  it  is  the  patient  rather  than  the  physician  who  is  usually  re- 
sponsible for  failure  and  a  chronic  resistant  infection.  To  this 
factor  of  reliability  which  so  many  gonorrheal  patients  lack  either 
because  of  their  youth,  their  ignorance  and  inexperience  or  their 
character  make-up,  add  the  expense  of  treatment  and  the  length  of 
time  involved  in  the  management  of  obstinate  cases,  and  it  is  small 
wonder  that  even  a  reasonably  efficient  free  dispensary  in  a  city 
such  as  New  York  is  obliged  to  admit  that  more  than  70  per  cent 
of  its  cases  of  gonorrhea  pass  through  it  hands  unbenefited,  and 
usually  make  only  one  visit.  The  man  with  a  gonorrhea  appeals  to 
everyone  as  a  "floater,"  and  he  inevitably  tends  to  respond  to  zero 
in  expectations  by  zero  in  cooperation  and  fulfillment.  That  the 
traditional  irresponsibilty  of  the  patient  with  gonorrhea  is  all  one- 
sided is,  of  course,  a  mistake.  Just  as  in  syphilis,  the  ability  to 
hold  patients  voluntarily  to  treatment  depends  at  least  in  part 
upon  the  physician,  and  upon  the  confidence,  response  and  coopera- 
tion he  is  able  to  inspire  in  those  he  treats.  Little  enough  of 
human  kindliness  and  consideration  is  extended  to  the  vast  mass  of 
victims  of  gonorrhea.  A  dispensary  "mill"  in  which  a  patient's  en- 
thusiasm for  cure  is  allowed  to  leak  out  in  the  jostle  of  a  basement 
line-up  and  any  signs  of  persistence  he  may  show,  meet  Avith  an 
exceedingly  impersonal  reception  or  actual  rebuff  in  the  form  of  a 
sour-visaged  intimation  that  he  is  a  nuisance,  trjdng  to  get  some- 
thing for  nothing,  is  no  place  to  encourage  cures  of  an  obstinate 
and  refractory  disease.  The  injection  of  a  little  of  the  human  ele- 
ment into  the  situation,  as  so  brilliantly  exemplified  in  the  pioneer 
methods  of  the  Brooklyn  Hospital  Dispensary  has  a  wonderful 
effect  in  bringing  the  value  of  effective  treatment  home  to  the  man 
with  gonorrhea  and  making  him  swear  by  it. 

Treatment  of  Chronic  Gonorrhea. — The  treatment  of  chronic  as 
distinguished  from  acute  gonorrhea  in  men  is  a  problem  of  wide 
variability,  and  may  call  for  superlative  skill.  The  seat  of  the 
inflammatory  process  whether  in  urinary  canal, 'prostate  gland, 
or  seminal  vesicle,  must  be  identified  by  careful  tests,  and  then 
treatment  directed  to  the  place  where  the  disease  maintains  its  foot- 
hold. Massage  of  the  prostate  gland,  injections  of  vaccines  made 
from  dead  germs  to  teach  the  body  to  fight  the  living  ones,  skilful 
instrumental  applications  of  medicines  to  points  deep  in  the  urinary 
system,  stretching  or  cutting  of  strictures,  and  similar  treatment 
form  a  group  of  procedures  whicli,  while  of  great  interest  to  the 


46 

genito-urinai^  surgeon,  offer  the  patient  a  much  less  agreeable  pros- 
pect. The  ounce  of  prevention  in  gonorrhea,  first,  last,  and  all  the 
time,  is  worth  many  tons  of  cure. 

The  "Bad  Cold"  He,  Fakes,  Drug  Stores  and  Quacks. — One  of 
the  great  obstacles  to  the  treatment  of  gonorrhea  is  an  ancient  lie 
expressed  in  the  now  hackneyed  quotation  of  a  current  remark  ''A 
dose  of  clap  is  no  worse  than  a  bad  cold."  This  monumental  false- 
hood is  at  last  being  nailed  by  the  combined  efforts  of  medical  pro- 
fession and  laity,  city,  state  and  nation.  With  such  an  impression 
of  the  disease  dinned  into  his  ears  by  tradition  and  associates  it  is 
little  wonder  that  the  young  man  of  the  average  type  finds  the 
I'estrictions  and  exactions  of  treatment  irksome.  It  is  little  wonder 
also  that  he  falls  an  easy  prey  to  all  sorts  of  quackery  and  to  the 
wiles  of  Jimmy  the  drug  clerk,  who  is  always  ''there"  with  the 
right  thing  to  take  "to  dry  up  a  dose"  and  has  no  unpleasant  ideas 
about  the  "water  wagon"  and  avoiding  sexual  relations  while  the 
cure  is  going  on.  Of  course  the  boy  who  "falls  for"  this  stuff 
wakes  up  with  a  jolt  some  day,  and  crawls  to  some  doctor's  office 
with  a  chronic  urethritis  that  may  never  clear  up  entirely,  and  a 
prostatitis  and  vesiculitis  that  have  snuffed  his  chances  for  all  that 
makes  his  later  life  what  it  ought  to  be.  There  are  no  superlatives 
adequate  to  describe  the  human  vermin  that  thrive  on  this  sort  of 
thing.  Among  them  must  be  reckoned  not  alone  the  advertising 
quack  and  the  men's  specialist,  but  those  commercial  concerns 
which  make  and  market,  and  those  drug  stores  which  permit  upon 
their  shelves  the  innumerable  "specifics"  for  the  self-cure  of  gon- 
orrhea and  "gleet,"  whose  alluring  promises  appear  upon  the  Avails 
of  every  bar  and  toilet  room.  The  "clap  doctor,"  with  his  waving 
hair  and  the  fatherly  look  and  voice,  is  still  with  us.  He  is  the  man 
who  plucks  the  inexperienced  boy  of  the  last  cent  he  can  beg,  bor- 
row or  steal,  and  then  turns  him  out  with  the  words  "That  morning 
drop  means  nothing;  you  are  cured."  Not  far  removed  from  his 
level,  to  our  shame  be  it  said,  is  that  type  of  physician,  fortunate- 
ly becoming  more  and  more  rare,  whose  conception  of  the  cure  of 
gonorrhea  ends  with  "drying  it  up,"  and  whose  ignorance  of  the 
microscope  and  all  the  modern  tests  for  cure  is  only  equalled  by 
his  scorn  of  them. 

Treatment  of  Gonorrhea  in  Women. — The  treatment  of  gonorrhea 
in  women  is  too  often  a  problem  of  peculiar  obstinacy.  The  mild- 
ness of  the  early  symptoms  in  one  group  of  cases  never  brings  them 
to  medical  attention  until  the  outlook  for  cure  is  almost  nil.  Even 
when  definite  symptoms  appear  they  are  usually  misinterpreted  into 
the  terms  so  often  used  by  profession  and  laity,  to  conceal  the  facts ; 
"cold"  on  the  bladder,  with  frequent  urination;  "leucorrhea,"  "ab- 


scess*^  following  the  first  sexual  relations  after  marriage;  "appen- 
dicitis," when  after  the  first  menstruation,  the  gonococeus  sets  up 
an  inflammation  in  the  tubes ;  and  "child-bed  fever"  perhaps  if  the 
ascent  of  the  infection  is  delayed  until  after  the  first  child  is  born. 
While  douches  and  washes  are  needed  in  the  treatment  of  gonorrhea 
in  the  woman,  their  unskilful  use  by  the  patient  in  the  self -treatment 
of  a  "leucorrhea"  often  does  no  more  than  reduce  the  infection  to 
latency  without  cure.  The  neck  of  the  womb,  the  womb  itself  and 
the  tubes,  as  well  as  the  glands  that  lie  at  the  opening  of  the  vagina, 
are  out  of  reach  of  such  methods.  Skilful  instrumentation  and 
prolonged  local  treatment  with  surgical  measures  are  usually  neces- 
sary. Much  of  the  surgery  that  follows  the  ascent  of  a  gonorrhea 
into  the  upper  genital  tract  in  a  woman  is  a  treatment  of  conse- 
quences rather  than  of  the  disease  itself,  since  the  germs  may  have 
died  out,  as  in  an  old  pus-tube  for  example.  Acute  gonorrhea,  in- 
vading the  abdomen  with  the  symptoms  of  peritonitis  often  can 
only  be  treated  by  waiting  for  nature  to  wall  the  process  off,  since 
to  cut  in  upon  it  while  it  is  active  is  to  spread  the  infection  all 
over  the  abdomen,  with  a  fatal  result.  These  are  the  cases  of 
"honey-moon  appendicitis"  that  many  a  pale,  drawn-faced  girl  can 
tell  of,  always  ending  with  that  unconscious  but  no  less  flagrant 
indictment  of  the  man  and  of  our  social  order,  "I  was  always  so 
well  until  I  married."  There  is  no  chivalry  about  gonorrhea. 
Upon  the  woman,  on  whom  life  at  best  bestows  the  larger  share  of 
pain,  it  inflicts  the  crowning  ignominies  and  deprivations.  Yet 
this,  many  good  people  would  pursuade  us,>is  our  ally;  "clap,"  the 
sturdy  guardian  of  our  moral  life. 

The  Obstinacy  of  Chronic  Gonorrhea  in  Women. — At  best,  then, 
the  disease  offers  women  a  less  satisfactory  outlook  than  it  does 
men.  Its  effects  and  their  treatment  are  too  often  finalities,  sealed 
with  the  loss  of  parts  and  functions  that  can  never  be  replaced. 
The  seriousness  for  society  of  the  chronicity  and  inveterate  tendency 
to  relapse  that  characterize  feminine  gonorrhea  can  best  be  appre- 
ciated in  dealing  with  those  women  who  are  the  reservoir  supply- 
ing it  to  the  world  at  large,  prostitutes,  public  or  secret.  It  is  a 
conservative  estimate  that  75  to  90  per  cent  of  them  have  the  dis- 
ease. Haines  found  that  after  gonorrhea  had  persisted  four  to 
six  months  without  treatment,  it  required  ten  to  twelve  months  of 
systematic  care,  such  as  it  would  be  out  of  the  question  for  any  but 
the  wealthy  to  afford  in  private  life,  before  the  symptoms  disap- 
peared and  the  bacteriologic  examination  became  negative.  The 
significance  of  such  a  statement  for  the  girl  who  through  a  misfor- 
tune or  a  false  step  acquires  the  disease,  stands  out  on  the  face  of 
it.     Stockman,  quoted  by  Af  Heurlin,  found  that  in  nearlv  half 


48 

(4G  per  ceni)  of  500  women,  gonococci  could  still  be  found  on  ex- 
amination months  after  the  patient  had  been  dismissed  as  cured. 
It  cannot  be  said  too  forcibly  that  there  are  no  clinical  signs  such 
as  a  leucorrheal  discharge,  etc.,  by  which  gonorrhea  in  a  woman 
can  be  unvarjangly  recognized  or  the  fact  of  her  cure  determined. 
The  microscope  and  the  judgment  of  the  expert  both  in  treatment 
and  the  determination  of  cure  are  the  courts  of  last  resort. 

The  Abortive  or  Suppressive  Treatment  of  Gonorrhea. — No  dis- 
cussion of  the  treatment  of  gonorrhea  in  men  or  women  is  com- 
plete without  mention  of  the  so-called  abortive  or  suppressive  treat- 
ment of  the  disease,  which  is  essentially  an  attempt  to  cure  or  ar- 
rest it  before  it  has  a  chance  to  extend  into  the  deeper  structures. 
It  deserves  mention  as  much  for  what  it  will  not  do,  as  for  what  it 
will.  It  may  be  said  in  a  general  way,  that  it  will  not  woik  at  the 
hands  of  the  patient  himself,  though  many  try  it,  nor  yet  of  a  phy- 
sician, who,  while  perhaps  skilled  enough  in  other  ways,  is  an  ama- 
teur or  out  of  date  in  the  treatment  of  gonorrhea.  It  may  also  be 
said,  that  the  attempt  of  the  patient  to  abort  a  gonorrhea  with  any 
of  the  strong  injections  which  he  may  obtain  from  officious  drug 
clerks  and  friends,  is  likely  not  only  to  fail  to  cure,  but  will  prob- 
ably make  the  ensuing  infection  very  much  more  serious  than  it 
would  have  been,  and  perhaps  make  it  chronic  and  unmanageable 
where  in  the  ordinary  course  of  events  with  average  management 
there  would  have  been  a  complete  recovery.  To  get  the  benefit  of  an 
abortive  treatment,  the  patient  should  be  in  the  hands  of  an  expert 
within  twenty-four  hours  after  the  first  burning  and  itching  ti  round 
the  urinary  opening,  and  the  first  signs  of  discharge  appear  For 
the  patient  to  delay  matters,  to  meddle  on  his  own  account  or  to 
seek  unskilled  advice  is  to  fail  and  perhaps  to  fail  disastrously. 

Hygiene  of  Gonorrliea. — So  much  has  been  said  about  the  im- 
portance of  the  patient's  cooperation  in  the  management  and  cure 
of  gonorrhea,  that  it  seems  worth  while  to  point  out  the  cardinal 
essentials. 

1.  Avoidance  of  excessive  exercise  during  the  acute  stage.  Pa- 
tients should  especially  avoid  much  walking,  and  dancing  is  flatly 
forbidden. 

2.  The  use  of  alcohol  is  exceedingly  dangerous.  The  man  who 
exposes  himself  to  gonorrhea  when  he  has  been  drinking  runs  a 
double  risk  of  getting  the  disease.  The  man  who  drinks  after  he  has 
gonorrhea  runs  a  triple  risk  of  keeping  the  disease.  One  of  the 
old-time  tests  for  the  cure  of  a  gonorrhea  used  to  be  that  of  seeing 
whether  the  discharge  would  start  up  again  after  a  "souse." 

3.  Much  water,  tea,  and  coffee,  should  be  drunk  to  flush  the  kid- 


49 

neys.  Spicy  foods  or  spicy  drinks,  such  as  ginger  ale,  are  not  to 
be  used. 

4.  Sexual  intercourse  during  acute  gonorrhea  is  usually  not  de- 
sired by  the  patient.  It  is  when  the  acute  symptoms  subside  that 
the  danger  comes.  To  have  sexual  intercourse  after  the  acute  stage 
while  a  gonorrhea  is  clearing  up  or  before  it  is  completely  cured, 
is  a  criminal  act,  and  will  moreover  start  a  new  attack  with  serious 
complications.  Sexual  excitement  without  intercourse  is  likely  to 
have  the  same  effect. 

.5.  Acute  gonorrhea  is  contagious.  Although  the  germs  die  out 
on  dry  surfaces,  they  can  be  transmitted  by  the  discharges  as  long 
as  they  are  moist.  The  strictest  care  in  not  touching  persons  or 
objects  or  carrying  the  hands  to  the  face  or  eyes  until  they  are 
washed  and  disinfected,  and  in  not  allowing  others  to  use  toilet 
and  personal  articles,  including  syringes  which  belong  to  the 
patient,  are  all  essential.  A  patient  with  acute  gonorrhea  should 
not  use  a  common  bath-tub,  or  sleep  with  others,  or  infect  the  toilet 
seat  by  contact.  If  there  are  children  in  the  house  all  precautions 
should  be  redoubled. 


50 

CHAPTER  V. 

j   THE  CURE  OF  GONORRHEA.  GONORRHEA  AND  MARRIAGE. 

^'Gonorrhea  is  Usually  Curable. — With  proper  care  the  large  ma- 
jority of  both  men  and  women  who  acquire  gonorrhea  can  recover 
completely.  The  problem  of  gonorrhea  from  the  standpoint  of  pub- 
lic health  is  less  that  of  ultimate  cure,  than  that  of  prolonged  in- 
fectiousness. Precisely  what  percentage  of  cases  is  ultimately 
cured  cannot  be  stated  in  statistical  form  at  the  present  day  since 
so  much  of  the  disease  never  even  gets  to  the  attention  of  those 
in  position  to  estimate,  much  less  record,  its  frequency.  It  is  cer- 
tainly very  large.  It  must  be  apparent  that  an  infection  which  is 
as  effective  as  gonorrhea  in  producing  childlessness,  must  have  had 
some  check  upon  its  career,  or  it  would  long  ago  have  extinguished 
the  race.  This  check  is  the  almost  spontaneous  tendency  which 
the  disease  exhibits,  to  run  its  course  and  get  well.  If  actual  and 
apparent  cure  were  identical,  and  an  acute  goiiorrhea  really  ended 
with  the  cessation  of  gross  signs  and  symptoms,  the  situation  would 
l)e  relatively  simple  from  the  public  health  standpoint.  It  is,  as 
has  been  said,  the  chronic  phase  of  the  disease  and  the  long  dura- 
tion of  the  infectiousness  of  it  in  cases  in  which  the  process  seems 
to  be  no  longer  active  that  perpetuate  its  hold  upon  us.  With  ref- 
erence to  the  duration  of  this  infectiousness  Keyes  estimates  that 
the  average  persistence  of  the  germs  of  gonorrhea  in  the  male 
urinary  canal  is  six  months  and  persistence  over  eighteen  months  is 
exceptional.  He  states  that  he  has  not  known  a  gonorrhea  to  re- 
main potentially  virulent  more  than  two  or  three  years — although 
he  believes  this  proves  the  possibility  of  indefinite  infectiousness  in 
some  cases.  In  women,  while  the  patients  usually  recover  in  a  few 
months  (Keyes)  the  exceptions  are  of  more  indefinite  duration, 
harder  to  recognize,  and  more  difficult  to  treat.  No  one  is  willing 
to  set  a  limit  on  the  period  of  a  woman's  infectiousness,  and  con- 
servative observers  have  the  greatest  hesitancy  in  naming  a  time 
at  which  a  woman  may  regard  herself  as  cured  and  no  longer 
capable  of  transmitting  the  disease. 

The  Carrier  of  Injection  the  Real  Danger. — The  fact  that  it  is 
not  its  incurability,  then,  so  much  as  the  activity  of  carriers  of  in- 
fection, which  perpetuates  gonorrhea,  points  the  way  to  effectual 
control.  So  long  as  individual  caprice  rather  than  respect  for  the 
public  health  governs  the  treatment  situation  and  makes  most  cases 
carriers  for  considerable  periods  before  cure  occurs,  we  can  expect 
no  encouraging  change  in  the  picture.  When  dispensary  patients 
can  make  one  visit  and  disappear,  when  private  cases  vanish  as 
soon  as  tbe  discharge  ''dries  up,"  when  thousands  of  cases  never 


51 

have  more  skilful  care  than  that  afforded  at  the  corner  drug  store, 
it  is  immaterial  whether  gonorrhea  is  curable  or  not,  since  so  much 
of  it  is  permitted  to  move  through  ordinary  life  without  let  or 
hindrance.  Education  of  the  public,  not  to  the  curability,  about 
which  they  already  have  an  unwarranted  optimism,  but  to  the  pro- 
longed infectiousness,  the  difficulties  of  the  treatment,  the  obstinacy 
of  the  disease,  will  be  more  likely  to  provoke  action.  Once  the  pub- 
lic grasps  the  situation,  cure  will  become  compulsory  and  therefore 
attainable  in  nearly  every  case,  and  carriers,  intentional  or  unin- 
tentional will  be  isolated  as  far  as  opportunities  to  transmit  gon- 
orrhea are  concerned,  with  the  thoroughness  with  which  typhoid 
and  diphtheria  carriers  are  today. 

Modern  Tests  for  Determining  Infectiousness  and  Cure. — The 
modern  tests  for  the  identification  of  gonorrhea  in  a  doubtful  case 
and  the  tests  to  determine  its  cure  should  be  summarized  because 
one  of  the  surest  ways  to  bring  about  their  general  adoption  is  to 
familiarize  the  public  with  what  to  expect  of  those  who  treat  the 
disease,  and  incidentally,  what  must  be  provided  for,  in  a  public 
movement  against  it.  The  detection  of  an  acute  early  gonorrhea 
while  sometimes  possible  without  the  microscope,  should  usually  be 
made  with  it  by  recognizing  the  germ  in  the  discharge.  A  point 
of  great  importance,  often  overlooked,  is  that  every  patient  with  a 
discharge  from  the  urinary  canal,  gonorrheal  or  otherwise,  should 
be  examined  for  coincident  evidence  of  the  presence  of  syphilis,  since 
an  unknown  but  probably  surprising  percentage  of  gonorrheas 
mask  the  beginning  of  syphilis.  In  chronic  gonorrhea,  the  micro- 
scope becomes  even  more  important,  in  the  examination  of  shreds 
in  the  urine  after  massage  of  the  prostate  gland  or  other  special 
manipulations,  in  cases  of  "morning  drop,"  etc.  A  single  exami- 
nation is  not  sufficient  to  show  the  absence  of  the  disease  especially 
in  women  and  three  or  four  examinations  or  even  more  may  be 
needed.  In  women  more  than  in  men,  the  absence  of  a  discharge 
or  leucorrhea  is  no  evidence  of  the  absence  of  the  disease.  Its 
stronghold  is  in  the  glands  and  these  must  be  searched,  sometimes 
with  the  aid  of  special  instruments,  in  cases  in  which  there  is  reason 
to  doubt  ordinary  findings.  Sometimes  it  is  necessary  to  try  to 
grow  the  germs  to  prove  they  are  gonococci.  There  exists  also  a 
blood  test  for  the  presence  of  gonorrhea,  recently  devised,  which 
rests  upon  principles  similar  to  those  governing  the  blood  test  in 
syphilis,  to  be  described  later.  The  blood  test,  while  new,  seems 
to  be  gaining  ground  as  a  valuable  means  of  recognizing  cases  in 
patients  that  otherwise  seem  to  be  well.  Among  all  these  elabora- 
tions and  technical  details,  use  of  the  microscope  stands  out  con- 
spicuously.    Any  (agency— from    the   clap-quack    and    drug   clerk 


53 

through  the  dispensary  to  the  licensed  practitioner  of  medicine— 
which  is  treating  gonorrhea  Avithout  the  use  of  the  microscope,  is 
playing  a  gambling  risk  against  the  patient,  trading  on  luck,  and 
contributing  directly,  without  excuse  or  extenuation,  to  the  aid  and 
comfort  of  the  enemy. 

GoiiarrJieal  Childlessness  in  Men  and  Women. — Much  that  should 
be  summarized  under  this  head,  has  been  suggested  in  the  foregoing 
discussion.  In  men,  gonorrhea,  aside  from  the  risk  of  infecting  the 
wife  which  exists  in  an  uncured  or  latent  case,  unfits  a  certain 
percentage  for  marriage  through  the  effect  of  the  inflammatory  pro- 
cess on  the  sperm  or  male  sexual  elements,  and  the  ducts  or  tubes 
through  which  they  pass.  Sterility  in  the  husband  is  variously  esti- 
mated as  responsible  for  from  17  to  25  per  cent  of  childless  mar- 
riages. It  should  be  understood  that  the  ability  to  have  sexual 
relations  may  exist  in  sterility.  It  is  the  failure  of  the  relation  to 
result  in  pregnancy  that  constitutes  the  sterility  for  which  the 
gonococcus  is  responsible.  It  is  one  of  the  supreme  ironies  of  fate 
to  have  the  woman  in  a  childless  marriage  appear  before  the  phy- 
sician, ready  to  submit  herself  to  every  manner  of  procedure  in- 
cluding even  serious  operations,  in  the  hope  of  curing  a  sterility  for 
which  the  husband  is  responsible,  while  he,  as  Morrow  says,  goes 
about  ''inflated  with  a  sense  of  his  own  virilit}\"  Such  charges  of 
sterility  in  the  wife,  for  which  the  husband  is  directly  or  indirectly 
responsible  have  formed  the  basis  of  separations  and  even  of  actions 
for  divorce.  Fortunately  it  has  now  become  well  understood  by 
the  medical  profession  that  proper  examination  of  the  husband  to 
prove  that  he  has  living  active  male  elements  is  essential  as  the 
first  move  in  determining  the  cause  of  a  sterility.  Yet  it  should 
not  be  imagined  that  all  male  sterility  is  due  to  gonorrhea.  For 
example,  Simmonds  estimates  that  61  per  cent  of  alcoholics  are 
sterile.  Moreover  it  must  never  be  forgotten  that  the  reproductive 
function  is  one  of  the  most  complicated  of  physico-chemical  mechan- 
isms and  a  marriage  may  be  childless  even  in  the  face  of  the  entire 
good  health  of  husband  or  wife.  The  U^yman's  snap  judgment  on 
the  presence  of  gonorrhea  in  a  childless  couple  therefore  has  at 
least  an  even  chance  of  being  wrong  instead  of  right.  Certain 
forms  of  sterility  in  the  man  due  to  the  effects  of  gonorrhea,  are 
not  incurable,  the  outlook  depending  somewhat  on  whether  active 
male  cells  exist  or  not. 

A  Child  Unborn. — The  burden  of  gonorrhea  in  marriage  falls 
overwhelmingly  upon  the  woman.  While  some  men  are  the  unfor- 
tunate victims  of  their  wives'  infection  tlie  rule  usually  "VAorks  the 
other  way.  Estimates  of  the  percentage  of  men  wlio  transmit  their 
gonorrheas  to  their  wives  vary  widely  from  5  to  45  per  cent.    Aside 


53 

from  the  invalidism  already  discussed,  for  Avhich  gonorrhea  is  re- 
sponsible in  marriage,  its  influence  on  the  perpetuation  of  the  race 
is,  as  such,  exceedingly  serious.  As  previously  noted,  about  50 
per  cent  of  all  absolute  and  one-child  sterility  is  due  to  gonorrhea, 
and  of  this  sterility,  75  per  cent  is  the  result  of  gonorrhea  trans- 
mitted to  the  woman  by  her  husband.  The  loss  to  the  good  of  the 
world  which  an  unborn  child  represents  is  in  no  sense  to  be  measured 
by  its  mere  place  in  a  numerical  series,  large  though  this  be.  In  no 
trivial  sense,  the  child  is  the  personal  immortality  of  its  bearers 
and  of  the  race.  A  child  unborn  is  a  defeated  purpose  and  a  bond 
unbound.  Being  unborn  is  more  costly  even  than  death,  since  the 
experiences  of  childbirth  and  death  are  at  least  part  of  that  dis- 
cipline without  which  man  and  wife  rarely  reach  the  full  develop- 
ment of  their  character  and  personality.  The  woman  who  through 
gonorrhea  has  not  known  the  bearing  and  rearing  of  a  child  carries 
an  inevitable  and  tragic  handicap — she  is  indeed  the  victim  of  an 
unfulfillment  whose  poignancy  can  never  be  subjected  to  mere  sta- 
tistical estimation. 

[/' Gonorrhea  and  ihe  Medloal  Examination  Before  Marriage. — The 
protection  of  marriage  from  the  effects  of  gonorrhea  is  one  of  the 
critical  eugenic  problems  of  our  time.  It  is  beset  by  difficulties 
which  are  part  and  parcel  of  the  status  of  the  genital  infections  in 
our  social  order,  and  of  the  medical  problems  involved  in  the  recog« 
nition  of  gonorrhea  itself.  It  may  be  said  to  begin  with,  that  so 
long  as  public  sentiment  does  not  compel  the  revocation  of  the  laws 
in  force  in  most  states  which  oblige  the  physician  to  remain  silent 
under  the  so-called  bond  of  professional  confidence  while  selfish 
and  irresponsible  men  or  women,  knowing  themselves  to  be  in  an 
infectious  state,  or  indifferent  to  the  question,  deliberately  marry 
healthy  partners,  a  certain  amount  of  marital  infection  will  per- 
sist. Such  a  revision  of  the  law  is  among  the  first  essentials  of  any 
attempt  to  control  carriers  of  the  disease.  On  the  other  hand,  the 
gonorrhea  transmitted  in  ignorance  by  inadequately  treated  and 
uncured  cases  is  a  much  larger  part  of  the  problem,  which  will  only 
be  fully  done  away  with  through  the  reform  of  the  whole  situation 
which  public  enlightenment  will  bring.  Medical  examination  before 
marriage,  while  it  has  not  yet  reached  the  status  in  public  sentiment 
and  law  which  it  deserves,  is  a  powerful  weapon  against  every  type 
of  gonococcus  carrier.  It  is  true  that  the  result  of  such  an  exami- 
nation is  less  trustworthy  in  women  than  men,  since  an  antiseptic 
douche  can  conceal  the  actual  status  of  the  case;  nevertheless  re- 
peated examinations  properly  carried  out  can  often  demonstrate 
the  infection  if  present.  Widows,  particularly  childless  ones,  no 
matter  Avhat  their  personal  character,  and  non-virgin  women,  are 


54 

legimate  objects  of  medical  suspicion.  It  is  true  that  in  isolated 
cases,  no  satisfactory  conclusion  can  be  reached,  although  such 
cases  are  rare  exceptions.  Medical  examination  of  men  is  irksome 
to  physician  and  patient,  but  capable  of  more  trustworthy  results. 
While  urination  before  examination  may  wash  away  a  morning 
drop,  roassage  of  the  prostate  gland  in  the  office,  followed  by  a  so- 
called  two-glass  test  and  microscopic  examination  will  usually  iden- 
tify a  gonococcus  carrier,  and  examination  of  the  urinary  canal  with 
an  instrument  called  the  endoscope  may  yield  findings  that  point 
toward  the  persistence  of  an  infection.  The  mere  absence  of  dis- 
charge in  a  man  who  has  had  a  comparatively  recent  gonorrhea  is 
never  to  be  trusted  as  evidence  of  fitness  to  marry.  Neither  is  the 
cursory  looking  over  too  often  given  such  cases,  to  be  regarded  as 
satisfactory.  The  development  of  the  blood  test  for  gonorrhea  may 
offer  a  valuable  aid,  but  one  whose  status  is  as  yet  not  fully  deter- 
mined. Every  man  who  has  had  a  gonorrhea — and  this  it  will  be 
recalled,  includes  about  50  per  cent  of  all  men — should  be  willing 
to  submit  to  thorough  examination  by  an  expert  chosen  by  the 
family  of  his  fiancee,  as  an  evidence  of  his  moral  as  well  as  physical 
fitness  to  become  her  husband.  The  completeness  of  the  examina- 
tion should  be  left  to  the  expert's  judgment. 

Protection  of  the  Fiancee. — When  gonorrhea  complicates  an  en- 
gagement as  it  too  often  does,  there  is  only  one  principle  to  follow ; 
postponement  until  a  cure  has  been  effected,  and  that,  a  cure  deter 
mined  by  the  microscope  and  time,  and  not  by  the  patient's  im- 
patience and  desires.  Here  again  a  new  conception  of  the  phy- 
sician's higher  obligation  to  society  will  allow  him  to  state  the 
facts  to  the  healthy  person  if  the  infected  individual  shows  an 
intention  to  marry  before  he  is  cured,  a  form  of  forced  control  of 
the  situation  that  is  too  often  the  only  way  of  aiding  the  woman. 
These  occurrences  are  anything  but  remote,  as  any  expert  can  at- 
test, and  until  they  are  dealt  with,  the  problem  of  gonorrhea  in 
marriage  will  remain  unsolved. 

.Protection  of  the  Pregnant  Woman  Against  Gonorrhea. — Tha 
seriousness  of  pregnancy  as  a  complication  of  gonorrhea  demands 
special  medical  measures,  both  for  the  sake  of  the  mother,  and  of  the 
child.  The  examination  of  women  who  have  such  symptoms  as 
"vaginal  abscess,"  burning  urination,  leucorrhea  and  abdominal 
pain  soon  after  marriage  or  during  pregnancy,  and  of  unmarried 
mothers  especially,  for  evidence  of  gonorrhea,  is  of  the  utmost  im- 
portance. The  examination  should  be  made  early  in  the  pregnancy 
if  possible  to  allow  for  painstaking  and  systematic  treatment  before 
the  birth  of  the  child.  The  life-sa^ang  value  of  such  a  measure  is 
so  great  that  it  should  under  no  circumstances  be  neglected. 


55 

'-^A  Warning  in  Regard  to  Double  Marital  Infection. — It  should 
not  be  forgotten,  as  an  explanation  of  more  than  one  embarrassing 
or  tragic  situation,  that  the  fact  that  a  man  and  wife  live  together 
or  have  sexual  relations  without  showing  evidence  of  gonorrheal  in- 
fection may  be  due  to  the  simple  fact  that  both  have  it,  albeit  in  a 
mild  or  quiescent  form.  The  separation  of  the  parties  to  such  a 
marriage  or  liaison  leaves  two  sources  of  infection  free  to  commu- 
nicate their  ailment  to  others,  the  more  easily  because,  having  failed 
to  note  any  evidence  that  they  had  infected  each  other,  they  would 
believe  themselves  to  be  normal.  Similarly,  the  treatment  of  one 
party  to  a  marriage  for  gonorrhea  calls  for  the  examination  and 
treatment  of  the  other,  since  it  is  only  under  the  rarest  of  condi- 
tions that  one  has  the  disease  without  the  other,  or  that  the  one 
can  be  cured  while  subject  to  repeated  risk  of  re-infection  by  the 
other. 

Remediadle  Weaknesses  of  the  Existing  Situation. — This  com- 
pletes for  the  time  being  the  consideration  of  the  medical  aspects  of 
gonorrhea  which  affect  its  status  in  a  public  health  campaign 
against  diseases  of  sexual  origin.  Age-long  underestimation  of  its 
seriousness  has  become  part  and  parcel  of  common  thought,  and 
only  prolonged  and  persistent  effort  at  re-education  will  finally  give 
the  disease  the  place  it  deserves  in  the  public  mind  side  by  side 
with  syphilis,  tuberculosis  and  cancer,  as  one  of  the  four  greatest 
surviving  plagues  of  the  human  race.  This  undeveloped  public 
sentiment  is  coupled  with  a  medical  handicap  that  is  yet  to  be 
overcome.  Slowness  and  some  uncertainty  in  treatment,  the  ab- 
sence of  the  spectacular,  and  the  unfamiliarity  of  the  medical  pro- 
fession with  certain  new  and  vitally  important  methods  for  the 
recognition  of  the  disease  in,  active  and  in  latent,  though  still  con- 
tagious cases,  deprive  a  campaign  of  some  of  the  dash  and  bril- 
liancy possible  in  syphilis,  but  form  no  insurmountable  obstacles. 
Too  few  great  minds,  it  would  almost  seem,  have  made  the  biology, 
the  physiology,  the  chemistry  of  the  gonococcus,  and  the  body 
which  it  invades,  their  life-work.  Throughout  this  field  as  through- 
out all  fields  of  medicine,  the  temporizing,  hand-to-mouth  treatment 
of  consequences  rather  than  causes  has  held  the  center  of  atten- 
tion. An  expenditure  of  effort  and  brain-power  equal  to  that 
which  has  been  lavished  on  the  results  and  the  wreckage  of  gon- 
orrhea, if  expended  upon  its  early  stages,  on  the  control  of  its  car- 
riers, and  on  its  prevention,  would,  within  a  generation  or  two, 
lead  to  new  knowledge  that  should  reduce  it  to  a  position  of  minor 
importance  in  the  ranks  of  disease.  It  is  not  the  association  of 
gonorrhea  with  a  moral  issue  such  as  that  of  prostitution  which 
maintains  its  foothold,    It  is  our  own  refusal  in  the  past  to  deal 


56 

with  it  radically  as  a  dangerous  infectious  disease  wherever  it  may 
be  found.  The  fact  deserves  re-emphasizing,  that  in  spite  of  its 
peculiar  obstinacies,  in  spite  of  the  lack  of  dramatic  and  rapidly  ef- 
fective methods  of  attack,  continued  insistence  upon  the  contagious- 
ness of  gonorrhea,  determined  focusing  of  every  effort  against  it, 
upon  its  transmissible  stage  and  upon  its  transmitter,  can  even 
today  remake  our  point  of  view,  and  begin  the  abolition  of  the 
disease.  When  gonorrhea  is  universally  understood  to  be  almost 
as  common  as  measles  and  more  terrible  than  smallpox — a  disease 
which  thrives  on  lies  and  cowardly  silence — the  way  will  open  for 
a  new  public  health. 


PART  III.     SYPHILIS. 


59 

CHAPTER  I. 
HISTORY,  CAUSE  AND  PREVALENCE  OF  SYPHILIS.i 

Tlie  Origin  of  the  Name. — Syphilis,  vulgarly  spoken  of  as  "pox" 
and  "blood  disease,"  is  one  of  the  most  remarkable  diseases  which 
affects  the  human  race.  The  name,  over  which  so  many  victims 
have  stuttered,  means  "a  lover  of  swine,"  and  was  first  applied  to 
the  disease  following  the  appearance  of  a  poem  by  Fracastor^  in 
1530,  in  which  a  dramatic  recital  of  the  symptoms  was  given  as  they 
appeared  in  the  person  of  the  principal  character,  Syphilus,  a  swine- 
herd, who  became  infected.  The  word  has  no  more  horrifying  or 
disgraceful  significance  than  would  the  name  "Job,"  if  used  as  a 
modern  term  for  boils,  with  which  that  Biblical  character  was 
afflicted. 

Syphilis,  a  Master  Disease. — Syphilis,  like  gonorrhea,  is  an  in- 
fection caused  by  a  specific  and  definite  germ.  It  is  a  master  dis- 
ease, the  peer,  and  indeed  the  superior  of  tuberculosis,  the  great 
"white  plague"  in  the  wide  range  of  its  influence  over  the  fate  of 
mankind,  present  and  future.  There  is  not  a  tissue  or  a  structure 
of  the  body  which  syphilis  cannot  afi'ect,  nor  is  there  an  aspect  of 
the  entire  science  of  medicine  in  which  it  will  not  be  encountered. 
Sir  William  Osier  coined  the  famous  phrase  which  for  all  time  ex- 
presses the  relation  of  syphilis  to  medicine  "Know  syphilis  in  all 
its  manifestations  and  relations,  and  all  other  things  clinical  will 
be  added  unto  you."  No  lane  is  so  long  that  one  may  not  find 
syphilis  at  its  turning.  The  disease  has  changed  the  destiny  of 
mankind  upon  the  earth.  If  it  should  cease  at  this  moment  to  be 
transmitted,  its  effects  would  not  disappear  from  the  world  within 
two  and  perhaps  three  generations.  Few  indeed  of  living  human 
beings  can  boast  an  ancestry  free  from  its  remote  effects. 

It  is  not  strange  therefore,  that  a  disease  of  which  such  state- 
ments can  be  made,  should  have  challenged  the  most  intense  iijter- 
est,  and  should  have  drawn  to  its  investigation  and  to  the  problem 
of  its  treatment  many  of  the  ablest  minds  of  medicine  and  the 
sciences  upon  which  medicine  is  founded.  There  is  about  it  a 
dramatic  quality  that  one  feels  the  lack  of  in  gonorrhea.  Infinitely 
clever,  infinitely  versatile,  even  a  little  inclined  to  chivalry  in  that 

>  Three  'discussions  of  syphilis  are  available  to  the  g-eneral  reader.     They  are: 

1.  Pusey,   W.   A.:   Syphilis  as  a   modern   problem.     Am.    Med.   Assn..    Chicago, 

1915.     An  eminently   readable  discussion,  containing  a  large  collection  of 
important  facts. 

2.  Vedder,  Col.  E.  B. :  Syphilis  and  public  health.*  Philadelphia,  Lea  &  Febi- 

g-er,  1918,  315  p.  This  is  a  monumental,  but  not  over-technical,  presenta- 
tion of  ever.v  phase  of  the  subject. 
.3.  Stokes,  J.  H.:  The  third  great  plague:  A  discussion  of  syphilis  for  everyday 
people.  Philadelphia,  Saunders,  1917,  204  pp.  This  book  is  written 
primarily  from  the  standpoint  of  the  patient  and  those  who  come  in 
contact  with  him. 
'  F'racastor,  H. :  Syphilis,  sive  morbus  gallicus.     Verona,   1530.     36  1. 


60 

Ihe  disease  is  in  general  less  severe  in  women  than  in  men,  S3'pliili> 
is  an  opponent  wortlij^  of  the  subtlest  resource,  the  most  indomit- 
able determination.  The  seeming  triviality  of  its  onset,  its  extraor- 
dinary skill  as  a  dissembler,  the  silent  but  none  the  less  terrible 
march  of  the  invading  host  of  spiral  germs  from  their  point  of  in- 
vasion through  the  blood  to  every  structure  of  the  body,  the  long 
years  of  silent,  evil  and  yet  wonderfully  skillful  work  they  do  under 
an  outward  aspect  of  good  health ;  the  variety  of  ailments  to  which 
syphilis  can  give  rise,  and  yet  the  dramatic,  the  almost  astounding 
effectiveness  of  proper  treatment,  make  it  decidedly  unique.  It  is 
little  wonder  that  Fracastor  felt  impelled  to  describe  it  in  poetry, 
for  bizarre  though  the  conception  may  seem,  syphilis  is  an  artist,  a 
craftsman  in  evil  beside  v\'hom  Machiavelli  and  Cesare  Borgia  were 
bunglers  and  dealers  in  crudity.  To  the  appreciation  of  its  course 
and  its  history  it  is  not  amiss  to  bring  a  little  of  the  spirit  of  the 
artist,  in  order  to  understand  the  workings  of  this  masterpiece  of 
evil,  this  most  .gifted  of  all  the  unholy  fellowship  of  devil's  aides. 
It  is  this  touch  of  knightliness  that  lifts  the  story  of  syphilis  from 
jthe  sordid  into  the  field  of  romance. 

\j  The  Historical  Aspects  of  Syphilis. — Syphilis  has  a  peculiar  his- 
tory. There  is,  of  course,  room  for  argument  as  to  its  antiquity 
and  its  origin,  and  it  is  scarcely  possible  as  yet  to  regard  the  ques- 
tion as  closed.  But  the  conception  of  the  so-called  American  source 
of  the  infection  seems  to  be  obtaining  a  wider  and  wider  acceptance. 
In  accordance  with  this  view,  it  would  appear  that  instead  of  hav- 
i'ng  the  universality  of  gonorrhea,  syphilis  was  suddenly  laid  upon 
the  doorstep  of  an  unsuspecting  world  by  the  sailors  of  Columbus 
in  1493,  upon  their  return  from  the  Island  of  Haiti,  in  which  the 
disease  was  known,  and  where  they  had  acquired  it.  Whether  or 
not  it  had  existed  in  the  old  world  prior  to  this  time,  certain  it  is 
that  from  the  time  of  this  fresh  importation  it  took  on  new  life. 
During  the  sixteenth  and  seventeenth  centuries  an  epidemic  of  the 
disease  swept  over  the  continent  of  Europe,  which,  for  virulent 
frightfulness  and  spectacular  horrors  totally  eclipsed  anything  seen 
except  in  the  rarest  of  cases  in  these  days.  The  combined  aid  of 
armies  and  voyagers  carried  it  apparently  into  every  corner  of  the 
habitable  earth.  Medicine,  still  enchained  by  the  lethargy  of  the 
Middle  Ages,  was  jolted  into  life  by  the  whirlwind  of  disaster.  On 
every  side  the  ablest  minds  the  art  could  muster  bent  themselves  to 
the  problem.  Clinical  knowledge  of  the  symptoms  of  syphilis 
sprang  into  existence  with  a  rapidity  scarcely  to  be  equalled  for  a 
time  by  progress  in  any  other  field  of  medicine.  We  liave  noted 
already  the  confusion  with  gonorrhea  fathered  by  John  Hunter  and 
later  set  right  by  Ricord.  With  the  work  of  tlie  latter,  and  of  Diday, 


61 

both  Frenchmen,  and  that  of  their  disciples,  the  modern  conceptions 
of  the  disease  came  one  by  one  into  being,  so  that  by  the  end  of  the 
nineteenth  century  there  lay  ready  for  the  fertilizing  power  of  labor- 
atory research,  a  rich  field  of  knowledge  of  the  human  aspects  of  the 
disease.  Syphilis  itself,  after  the  violence  of  its  epidemic  phase, 
seemed  to  subside  into  the  subtle  and  malevolent  cleverness  we 
know  so  well  today.  Instead  of  descending  upon  the  victim  as 
a  thunderbolt,  literally  dissolving  him  bone  and  body  into  a  mass 
of  carrion,  it  now  expresses  itself  less  luridly  but  none  the  less  ef- 
fectively in  the  form  of  grave  diseases  of  the  heart  and  kidneys, 
in  death  from  impairment  of  the  great  blood  vessels,  in  damage  to 
sight  and  hearing,  in  loss  of  the  power  to  move  through  the  death 
of  nerves,  in  snuffing  out  of  the  mind  itself. 

The  Neio  Knowledge  of  Syphilis. — In  the  later  years  of  the  nine- 
teenth century,  a  change  long  prepared  for  and  foreshadowed  came 
over  the  whole  face  of  medicine.  The  sciences  upon  which  the  art 
must  always  rest  for  the  foundation  of  its  advance,  had  come  into 
existence,  and  grew  under  the  genius  of  men  like  Pasteur,  the 
founder  of  bacteriology,  intg  a  fountain-head  of  inspiration  and 
new  knowledge.  With  almost  miraculous  suddenness  the  whole  as- 
pect of  our  knowledge  of  syphilis  changed  with  the  changing  situa- 
tion in  medicine.  One  epochal  discovery  trod  the  heels  of  another 
in  the  decade  from  1900  to  1910.  The  whole  fabric  of  the  new 
science  of  syphilology  was  welded  together  by  men  whose  labors  de- 
serve Homeric  words  of  praise.  Schaudinn  and  Hoffmann,  Match- 
nikoff,  Roux,  Bordet,  Wassermann,  Ehrlich,  Hata,  unassuming  men 
drawn  from  all  the  great  intellectual  sources  of  human  life,  carry- 
ing on  their  labors  in  the  seclusion  and  quiet  of  laboratories,  were 
none  the  less  the  peers  and  fellow-workers  of  Vulcan,  who  in  the 
heart  of  a  volcano,  forged  the  armor  of  the  gods.  To  the  tremend- 
ous constructive  brain  power  of  these  men,  the  grasp  that  Ehrlich 
and  Hata  had  of  the  chemistry  of  arsenic  and  the  biology  of  the 
germ  of  syphilis,  the  eye-sight  and  the  experience  of  Schaudinn  who 
could  see  in  the  germ  he  discovered,  with  the  ordinary  lenses  of  the 
microscope,  structures  that  lesser  men  can  barely  see  today  with  the 
artificial  aids  he  despised  or  did  not  have — to  these  men  we  do 
homage  in  the  mere  mention  of  the  new  knowledge  of  syphilis. 
"Though  they  be  not  sought  for  in  the  council  of  the  people,  nor 
be  exalted  in  the  assembly,"  they  have  re-made  the  destiny  of  man 
upon  the  earth. 

The  Discovery  of  the  Germ  and  the  Transmission  of  Syphilis  to 
Animals. — Few  more  important  occurrences  could  be  imagined  than 
the  identification  on  April  5,  1905,  by  Schaudinn  and  Hoffmann,  the 
former  a  zoologist  and  tl\e  latter  a  syphilologist,  of  the  germ  which 


62 

is  now  practically  universally  accepted  as  the  cause  of  syphilis. 
Innumerable  germs  had  been  suspected  before  this,  but  had  failed  to 
stand  critical  study.  The  identification  of  syphilis  as  an  infection 
and  the  recognition  of  its  cause  combined  with  the  proof  furnished 
by  Metchnikoff  and  Roux  that  it  could  be  transmitted  to  certain 
animals  and  could  therefore  be  studied  experimentally,  furnished 
the  groundwork  upon  Avhich  rests  the  whole  fabric  of  the  modern 
recognition  and  treatment  of  the  disease.  Not  that  syphilis  was  not 
recognized  before,  or  that  its  treatment  had  not  met  with  a  measure 
of  success.  But  the  identification  of  the  germ  in  the  very  first  sore 
of  the  disease  makes  possible  a  prospect  of  complete  cure  that  is 
incomparably  greater  than  anything  the  older  knowledge  could 
offer.  The  transmission  of  the  disease  to  animals  made  possible 
the  invention  of  the  synthetic  compound  of  arsenic  known  as  "606" 
by  Ehrlich,  which  produces  radical  effects  upon  the  disease  in  all 
its  stages,  and  controls  its  contagiousness  in  a  way  that  alters  our 
whole  outlook  upon  it  as  a  problem  in  public  health. 

The  Spirochaeta  Pallida  and  its  Recognition  in  Early  Syphilitic 
Sores. — -The  germ  of  syphilis  is  calle'd  the  Spirocheta  pallida^  the 
first  word  describing  its  corkscrew  shape,  and  the  second  the  ex- 
treme difficulty  with  which  it  can  be  stained  with  dyes  to  make 
it  visible.  It  is  exceedingly  minute,  and  is  best  observed  in  the  liv- 
ing  state,  when  freshly  taken  from  the  secretions  of  certain  syph- 
ilitic sores,  the  study  being  made  under  the  highest  powers  of  the 
microscope,  with  the  aid  of  a  special  instrument  called  the  "dark 
field,"  which  shows  the  germs  in  a  beam  of  reflected  light,  much 
as  motes  appear  in  a  sunbeam  in  a  darkened  room.  It  is  also  pos- 
sible to  use  stains  as  in  the  case  of  the  gonococcus,  though  they  are 
less  satisfactory.  The  germ  of  syphilis  has  been  so  recently  dis- 
covered, and  the  subject  of  syphilology  in  general  has  been  so  poorly 
taught  in  medical  schools  of  the  past  generation  that  many  men 
called  upon  to  deal  with  syphilis  today  have  little  or  no  conception 
of  the  importance  of  the  germ  in  the  recognition  of  the  disease  in 
the  living  patient,  and  too  often  have  never  seen  it  or  learned  how 
to  find  it  when  occasion  demands.  Yet  it  is  not  too  much  to  say 
that  the  time  has  come  when  the  ability  to  find  the  Spirocheta  pal- 
lida in  certain  sores,  especially  the  early  ones  of  syphilis,  and  the 
mechanical  equipment  for  doing  it,  are  absolutely  prerequisite  to 
professional  fitness  to  diagnose  or  treat  the  disease.  British  naval 
medical  officers  in  the  first  year  of  the  war,  showed,  for  example, 
that  of  671  men  with  venereal  sores,  63.4  per  cent  were  recognized 
at  once  as  syphilitic  by  the  use  of  the  dark  field  and  only  13.9  per 
cent  were  later  found  to  be  syphilitic  by  subsequent  blood  tests. 

1  A  number  of  investigators  consider   "Treponema    pallidum"   the   proper   term. 


63 

When  we  recall  that  in  1911  only  about  14  per  cent  of  early  syphilis 
in  the  United  States  army  was  recognized  during  the  stage  of  the 
first  sore  or  chancre,  and  in  1915  only  22  per  cent,  we  can  appre- 
ciate the  immense  advance  made  possible  through  the  newer  meth- 
ods, by  which  it  is  safe  to  say  no  less  than  80  per  cent  of  all  syph- 
ilitics  seen  in  the  stage  of  the  first  sore  can  be  recognized  and  given 
the  100  per  cent  chance  for  cure.  No  physician,  and  no  hospital 
or  dispensary  which  is  not  equipped  to  identify  the  germ  of  syphilis 
or  is  unwilling  to  see  that  the  patient  gets  the  benefit  of  such  knowl- 
edge elsewhere  if  it  is  called  for  by  the  nature  of  his  case,  has  any 
business  to  pretend  to  deal  with  early  syphilis.  The  statement 
seems  radical,  yet  upon  its  literal  acceptance  depends  more  than 
half  of  our  hope  of  future  progress  based  on  early  and  complete 
cure. 

The  Prevalence  of  Syphilis^. — Before  considering  the  nature  of 
the  disease  itself,  a  few  words  should  be  said  about  its  prevalence. 
Here  again,  as  in  the  case  of  gonorrhea,  estimates  rather  than  exact 
statistics  must  be  largely  drawn  upon.  It  should  be  recalled  that 
a  large  amount  of  syphilis  goes  about  unrecognized  in  the  ordinary 
course  of  events,  until  some  of  its  effects  appear,  or  an  incidental 
ailment  brings  the  patient  into  the  hands  of  someone  who  applies 
the  modern  tests.  So  greatly  has  the  blood  test  for  syphilis  in- 
creased our  power  to  recognize  the  disease  that  the  older  figures 
have  lost  much  of  their  value.  Yet  even  these  based  in  the  vast  per- 
sonal experience  of  men  like  Fourier,  estimated  the  percentage  of 
syphilis  among  the  adults  of  large  cities  like  London  and  Paris  as 
from  10  to  13  per  cent.  A  survey  of  British  working  men  seemingly 
in  good  health,  made  by  Collie,  showed  9  per  cent  to  have  syphilis. 
Class  variations  and  age  are  a  large  factor  in  estimating  the  preva- 
lence of  the  disease  and  no  consideration  is  complete  which  omits 
them.  For  example,  Vedder  came  to  the  conclusion  that  20  per 
cent  represented  a  fair  average  for  the  amount  of  syphilitic  infec- 
tion among  young  men  who  enlist  in  the  army,  and  that  among  men 
representing  the  grade  which  applies  for  commissions,  trains  at 
West  Point  or  enters  our  colleges,  2  to  5  per  cent  is  the  approximate 
prevalence.  Among  hospital  patients  estimates  range  from  10  to 
20  per  cent  based,  however,  quite  largely  upon  the  blood  test  rather 
than  upon  combined  blood  test  and  medical  examination,  which  in- 
variably results  in  a  higher  figure.  Among  young  women  Vedder 
estimates  that  the  percentage  fluctuates  between  3  and  20  per  cent 
depending  on  age,  marital,  condition,  social  status,  etc.  Among 
private  patients  from  10  to  20  per  cent  have  syphilis,  among  chil- 

1  Those  especially  interested  in  this  question,  .and  all  public  health  officers,  should 
read  the  remarkably  complete  presentation  of  this  subject  by  Col.  E.  B  Vedder  in 
"Syphilis  and  public  health,"  loc  cit. 


64 

dren  3  to  10  per  cent.  Among  negroes  in  apparent  healthy,  the  per- 
centage varies  from  25  to  30  per  cent,  among  the  sick  from  40  to 
50  per  cent.  Among  criminals  the  range  is  from  20  to  40  per  cent, 
among  the  insane  (male  whites)  20  to  35  per  cent,  among  prostitutes 
from  50  to  100  per  cent.  There  are  some  notable  national  figures, 
especially  those  for  parts  of  Kussia  in  which  it  was  estim^ated  that 
95  per  cent  of  the  peasant  population  had  the  disease.  While  such 
spectacular  estimates  can  have  no  general  significance,  they  suggest 
the  extent  of  the  problem  in  nations  with  a  low  physical  and  mental 
standard  of  living.  Estimates  for  the  continental  countries  such 
as  Germany  and  France  do  not  differ  materially  from  those  quoted 
lor  the  United  States.  The  question  as  to  whether  or  not  syphilis 
is  on  the  increase  is  one  difficult  of  determination,  since  the  newer 
methods  of  recognizing  the  disease  are  creating  an  impression  of 
increase  which  may  be  more  apparent  than  real.  Pusey  believes 
that  on  the  whole  there  is  no  evidence  to  show  that  it  is  becoming 
more  prevalent  than  in  the  past. 

It  needs  no  comment  to  carry  home  the  meaning  ot'  these  figures 
to  every  thinking  man  and  woman.  Nothing  could  more  efifectively 
shatter  the  notion  that  syphilis  is  the  heritage  of  the  unfavored 
few,  the  trophy  of  debauch,  the  sign-manual  of  the  down-and-out. 
Syphilis  is  one  of  the  most  widespread  of  all  infectious  diseases. 
Its  victims  are  numbered  in  millions,  not  in  hundreds.  Not  a  man 
lives,  or  a  woman,  who  does  not  elbow  it  every  day,  whose  house 
has  not  seen  its  entry  and  departure,  who  may  not  at  any  hour 
have  his  name  added  to  the  rolls.  While  to  be  sure  there  are 
variations  in  the  nearness  or  remoteness  of  the  risk,  never  does  it 
become  so  distant  that  any  one  of  us  can  sit  by  and  say  in  smug 
unconcern  "This  is  not  my  affair."  While  it  is  not  so  prevalent 
as  gonorrhea,  it  may  beset  us  perhaps  in  disguise,  and  but  too  often 
in  dangerous  contagious  form,  in  those  unsuspecting  hours  when  we 
believe  ourselves  at  ease  among  our  friends.  Syphilis  is  too  cun- 
ning a  craftsman  in  evil  to  permit  the  limitation  of  his  labors  to 
tbe  few. 


65 

CHAPTER  II. 

THE  COURSE   OF   SYPHILIS— PRIMARY  AND 
SECONDARY  STAGES. 

The  Stages  of  Syphilis. — A  knowledge  of  the  course  of  syphilis  and 
the  effect  produced  by  the  germ  upon  the  body  is  essential  to  any 
comprehension  of  the  problem  in  public  health  which  it  presents. 
Reference  has  already  been  made  to  the  fact  that  it  can  affect  any 
portion  of  the  body  and  in  such  a  variety  of  ways  as  to  make  its 
manifestations  almost  synonymous  with  the  whole  field  of  medicine 
itself.  There  is  indeed  scarcely  a  known  condition  due  to  other 
causes  which  syphilis  cannot  passably  imitate.  The  conventional 
division  of  the  disease  into  stages  has  also  been  foreshadowed  in  the 
preceding  discussion.  The  usual  terms  for  these  stages  are  primary, 
secondary  and  tertiary.  They  are  arbitrary  divisions  based  on  time 
rather  than  on  the  course  and  peculiarities  of  the  disease.  A  more 
rational  grouping  would  be  into  an  early  local,  a  generalized  or  dis- 
seminate stage,  a  stage  of  recurrences  and  latency,  and  finally  so- 
called  late  syphilis,  including  what  was  formerly  spoken  of  as  quar- 
ternary  syphilis  of  the  nervous  system — that  is  locomotor  ataxia  and 
general  paralysis  of  the  insane.  These  divisions  while  taking  ac- 
count of  time,  are  also  based  upon  the  behavior  of  the  germ  and  the 
reaction  of  the  body  to  its  invasion. 

ThiB  Primary  or  Localized  Stage — The  Chancre. — Early  local  or 
primary  syphilis  covers  essentially  the  period  from  the  appearance 
of  the  first  sore,  to  the  time  when  the  germs  spread  to  all  parts  of 
the  body.  The  germ  of  syphilis  gains  entrance  to  the  body  usually 
through  an  abrasion  or  wound  in  the  skin  or  the  thin,  moist,  red 
mucous  surfaces.  This  abrasion  may  be  so  small  that  it  is  only 
visible  under  the  microscope,  so  that  the  seeming  wholeness  of  the 
skin  or  mucous  surfaces  is  no  evidence  whatever  that  the  germ  has 
not  found  an  entrance.  When  the  Spirocheta  pallida  enters  the 
body  it  remains  for  some  time  at  the  place  where  it  gained  entrance, 
the  germs  multiplying  and  setting  up  in  the  surrounding  tissues  a 
reaction  which  is  essentially  a  mild  chronic  inflammation.  In  an  in- 
fection with  the  gonococcus  there  is  at  least  a  passable  fight,  and 
that  quite  promptly.  The  spirochete  of  syphilis  on  the  other  hand 
arouses  much  less  opposition,  unfortunately,  and  has  a  correspond- 
ingly greater  opportunity  to  gain  a  foothold.  From  the  time  the 
germ  enters  the  body  until  the  first  signs  of  a  sore  or  reaction  ap- 
pear a  period  of  several  days  to  several  weeks  may  elapse,  in  which 
the  patient  has  no  idea  of  the  danger  he  is  in.  If  he  knew  himself 
to  be  infected,  this  so-called  period  of  incubation  would  be  the  ideal 
time  in  which  to  take  strong  treatment,  since  the  germs  could  be 


66 

killed  off  with  comparative  ease.  In  cases  where  a  person  is  known 
to  have  been  exposed,  it  is  in  fact  becoming  good  j^ractice  to  fore- 
stall the  appearance  of  any  sore  by  treating  him  on  the  chance  that 
one  will  develop.  The  patient,  however,  does  not  usually  discover 
his  situation  until  a  small  lump,  a  chafe,  or  an  actual  ulcer  ap- 
pears at  the  place  where  the  germs  entered.  This  sore  is  the  first 
outspoken  evidence  of  syphilis  and  is  called  the  chancre  (pronounced 
shan-ker)  or  primary  lesion.  During  the  first  few  days  of  its  ap- 
pearance, the  overwhelming  majority  of  the  germs  of  the  disease 
are  in  it  and  in  its  immediate  neighborhood.  They  have  not  as  yet 
spread  to  any  significant  extent  to  other  parts  of  the  body.  Their 
presence  makes  the  discharges  from  the  chancre  extremely  con- 
tagious and  dangerous  for  others.  But  from  the  patient's  stand- 
point the  fact  that  they  are  still  in  one  place  and  have  not  as  yet 
invaded  the  body  makes  this  the  golden  moment  for  cure. 

Cure  in  the  Early  Stage  {Abortive  Cure). — The  patient  is  warned 
by  the  sore  that  there  is  something  wrong,  if  he  knows  enough  to 
take  it  seriously.  If  the  germs  are  immediately  found  by  the  dark 
field  microscope  and  powerful  doses  of  the  newer  drugs  such  as 
"606"  are  given  directly  into  his  blood  before  the  spread  of  the 
germs  takes  place,  the  process  is  stopped  before  it  has  started  so 
to  speak,  all  the  germs  can  be  killed  ofif,  and  a  complete  and  rapid 
cure  results.  This  curing  of  the  disease  in  the  earliest  days  of  the 
primary  lesion  is  called  "abortive"  cure.  It  should  be  reiterated 
that  this  is  only  possible  in  the  earliest  days,  almost  the  earliest 
hours  of  the  visible  chancre.  No  test  of  the  blood  will  prove  the 
presence  of  the  disease  at  this  time,  for  once  the  blood  shows  it, 
the  chance  for  abortive  cure  is  gone.  Abortive  cure  is  one  of  the 
great  hopes  of  humanity  in  its  battle  against  syphilis.  The  need 
for  it  should  be  preached  from  housetops,  as  was  the  outdoor  treat- 
ment of  tuberculosis.  While  its  use  is  still  in  its  infancy,  we  have 
good  reason  to  believe  that  if  it  could  be  applied  throughout  the 
world  in  conjunction  with  social  and  educational  as  well  as  medi- 
cal preventive  measures,  syphilis  could  be  wiped  out  as  completely 
as  malaria  can  be  by  the  extermination  of  the  mosquito. 

Just  when  the  opportunity  for  abortive  cure  ends  cannot  be  de- 
termined as  yet  by  any  means  we  know.  One  thing  is  sure — abor- 
tive treatment  cannot  begin  too  soon  and  it  can  easily  be  too  late. 
The  first  four  to  ten  days  of  a  sore  seen  from  its  very  beginning 
represent  the  best  guess  as  to  the  upper  limit  of  time  in  which  it 
is  possible  to  obtain  an  abortive  result. 

Difficulties  in  Recognizing  a  Si/philitio  Chancre. — Emphasis  has 
already  been  placed  on  the  fact  that  there  is  no  reliable  way  of 
telling  from  its  appearance  whether  a  genital  sore  is  a  chancre  or 


G7 

not.  The  microscope  is  the  first  resort.  Chancres  may  be  of  any 
size  and  appearance,  and  may  develop  anywhere.  It  is  even  be- 
lieved that  they  may  be  altogether  absent  and  the  patient  still  ac- 
quire syphilis.  It  is  not  a  rare  thing  for  a  chancre  to  occur  inside 
the  canal  through  which  the  urine  passes  or  just  at  the  opening  and 
to  be  masked  by  the  discharge  of  a  gonorrhea  acquired  at  the  same 
time.  In  women  it  may  develop  in  the  vagina  or  on  the  neck  of  the 
womb.  Many  intelligent  and  entirely  truthful  patients  with 
syphilis  can  give  no  account  whatever  of  a  chancre  though  they 
admit  having  had  gonorrhea.  Still  others,  women  especially,  can 
give  no  account  of  either  syphilis  or  gonorrhea,  and  yet  they  have 
syphilis.  It  has  been  estimated  that  as  high  as  40  per  cent  of  men 
and  60  x^er  cent  of  w^omen  having  syphilis  are  not  aware  of  the  on- 
set of  their  infection  as  such,  or  have  forgotten  its  trivial  begin- 
nings. It  cannot  be  too  strongly  said  that  a  chancre  may  be  so 
small,  so  unobtrusive,  so  painless,  so  well  concealed  in  some  fold  of 
skin  or  mucous  membrane  that  even  an  intelligent  and  observing 
patient  will  wholly  overlook  it.  Add  to  these  overlooked  infections 
the  innumerable  misinterpretations  of  chancres  which  are  dubbed 
'•chancroids,"  "soft  sores,"  "chafes,"  cold  sores,  etc.,  and  the  real 
wonder  becomes,  not  that  so  much  early  syphilis  goes  unrecognized, 
but  that  any  of  it  is  recognized  at  all.  In  women  especially,  as 
already  intimated,  the  opportunities  for  a  chancre  to  pass  un- 
noticed are  much  greater  than  in  men.  The  genitalia  are  less  ac- 
cessible, and  a  chancre  can  occur  for  example  on  the  neck  of  the 
womb  or  in  the  vagina  without  the  victim's  ever  realizing  the  fact 
or  being  aware  that  she  is  in  an  infectious  condition.  It  is  indeed 
a  rarity  for  women  to  have  an  infection  recognized  in  the  primary 
stage  and  for  them  therefore  the  outlook  for  abortive  cure  based 
on  the  identification  of  the  primary  lesion  is  vanishingly  small. 
Aside  from  those  few  cases  which  can  be  treated  on  the  knowledge 
that  they  have  been  exposed  even  though  no  chancre  can  be  found, 
the  problem  of  controlling  syphilis  by  the  treatment  of  women  will 
largely  resolve  itself  into  putting  a  stop  to  their  infectiousness  as 
soon  as  the  disease  has  developed  far  enough  to  be  recognized  by 
other  signs. 

The  Spread  of  the  Germs  from  the  Chancre  to  the  Body. — 'From 
the  chancre  or  primary  lesion,  if  nothing  is  done  to  stop  the  prog- 
ress of  the  disease,  the  germs  of  syphilis  travel  by  way  of  the  lymph 
channels  at  first,  to  the  nearest  set  of  glands  or  kernels,  where  they 
provoke  a  reaction  which  shows  itself  as  a  local  swelling.  A  marked 
swelling  of  the  kernels  or  glands  in  the  neck  or  under  the  jaw,  com- 
ing on  rather  rapidly,  with  a  very  sore  throat  or  a  sore  on  the  lip, 
should  at  once  arouse  the  suspicion  that  the  sore  is   a  chancre. 


68 

When  the  chancre  occurs  on  the  genitals  the  swelling  is  less  char- 
acteristic, and  more  likely  to  occur  with  other  types  of  infections. 
This  invasion  of  the  lymph  glands  is  the  last  phase  of  the  primary 
stage,  and  indeed  when  it  becomes  definite  the  local  period  of 
syphilis  is  over.  When  the  lymph  glands  have  ceased  to  serve  as  a 
defense,  a  sudden  change  in  the  whole  aspect  of  the  disease  occurs, 
The  germs  abruptly  get  into  the  blood  stream  in  enormous  numbers, 
and  are  carried  forthwith  to  every  single  structure  of  the  body. 
While  a  few  germs  may  have  entered  the  blood  before  the  grand  at- 
tack, the  sudden  rush  is  an  attack  in  force,  a  "Big  Push"  which 
places  the  patient  once  and  for  all  beyond  the  reach  of  the  abortive, 
hundred  per  cent  cure.  The  infection  has  now  become  generalized, 
as  we  say,  and  syphilis  is  a  constitutional  disease  from  that  moment. 
While  the  germs  of  gonorrhea  gain  access  to  the  blood  in  occasional 
cases  and  produce  symptoms,  syphilis  differs  from  gonorrhea  in  that 
this  invasion  is  invariable,  and  that  owing  to  peculiarities  in  the 
germ,  it  involves  consequences  vastly  more  serious  and  far  reaching 
than  those  of  systemic  gonorrhea. 

The  Generalized  or  Secondary  Stage. — The  generalization  of  the 
infection,  which  usually  occurs  from  the  first  to  the  fourth  week 
after  the  appearance  of  the  chancre,  marks  the  beginning  of  the 
secondary  stage.  Before  anything  appears  the  patient  may  have 
premonitions  of  trouble  in  the  form  of  headaches,  a  drop  in  weight 
and  a  feeling  of  being  under  the  weather.  Then  in  the  large  ma- 
jority of  cases  the  thing  which  constitutes  syphilis  in  popular  imag- 
ination occurs.  The  patient  usually  ''breaks  out"  with  some  kind 
of  skin  eruption  which  on  account  of  the  wide  distribution  of  the 
germs  tends  to  be  general  over  the  body. 

BypMlitiG  Eruptions  and  their  Variations;  Gornmon  Misconcep- 
tions.— Syphilitic  secondary  eruptions  are  comparable  to  many 
other  eruptions  in  skin  diseases.  They  take  on  the  widest  varieties 
of  forms,  ranging  from  a  few  faint  pink  spots  in  the  armpits  and 
flanks,  which  the  patient  may  not  even  see,  to  great,  round,  j)unched 
out  ulcers  that  may  riddle  his  skin  like  a  burst  of  shrapnel.  The 
recognition  of  syphilitic  secondary  eruptions  is  at  times  none  too 
easy  a  matter  for  the  expert  and  it  may  be  a  bugbear  for  the  aver- 
age doctor.  If  it  is  hard  for  him,  it  is  apparent  that  no  layman 
has  any  business  to  take  upon  himself  the  task  of  deciding  the 
matter.  The  arrogant  self-sufficiency  with  which  occasional  per- 
sons will  set  themselves  to  wreck  the  lives  of  unfortunates  with  skin 
diseases  on  a  non-medical  decision  that  they  have  some  "bad  dis- 
ease" is  one  of  the  wonders  of  that  combination  of  stupidity  and 
ignorance  against  which  the  gods  themselves  fight  in  vain.  Persons 
with  psoriasis  especially,  a  harmless  but  disfiguring  affair,  are  sub- 


69 

ject  to  cruel  and  scandalous  mis  judgments  from  this  source.  The 
author  has  known  ministers  to  all  but  lose  wife,  church  and  reputa- 
tion through  the  unprincipled  activities  of  amateur  dermatologists 
in  their  congregations.  There  can  be  but  one  honorable  course  for  an 
outsider  to  pursue  when  confronted  with  an  eruption  on  the  person 
of  friend  or  acquaintance.  If  it  is  any  of  the  outsider's  Jbusiness, 
let  him  frankly  ask  the  friend  for  a  statement  from  his  medical  ad- 
visor or  advise  him  to  carry  such  a  statement  about  with  him.  If 
it  is  not  the  outsider's  business,  let  him  keep  silent. 

Syphilitic  Eruptions  and  the  General  Pu'blic. — Fortunately  two 
considerations  minimize  the  importance  of  syphilitic  skin  eruptions 
for  the  general  public.  In  the  first  place,  they  are  practically  never 
contagious  when  on  the  free  skin  of  the  body  or  the  face.  It  is  only 
when  some  of  the  bumps  occur  in  moist  spots  such  as  the  armpits  or 
the  groins,  where  their  tops  can  be  rubbed  off,  that  the  germs  get 
an  opportunity  to  escape.  Even  in  such  cases  the  damage  can  only 
be  done  to  those  who  come  into  intimate  contact  with  the  body  or 
the  moist  underclothing  of  the  syphilitic.  No  dry,  unbroken  skin 
surface  transmits  the  disease.  In  the  second  place,  a  syphilitic 
skin  eruption  if  prominent  enough  to  draw  the  public  eye  sends  the 
person  at  once  for  treatment,  with  the  result  that  it  is  usually 
rapidly  cleared  up. 

The  Dangerous  Contagious  Manifestations  of  Secondary  Syphilis. 
—Secondary  syphilis  is,  however,  accompanied  by  outbreaks  which 
are  full  of  danger  for  others,  and  the  danger  is  the  greater  because 
it  is  the  dangerous  sores  which  are  usually  hardest  to  recognize  or 
least  suspected  of  having  any  connection  with  the  disease.  Sec- 
ondary syphilis  shows  a  marked  tendency  to  involve  the  throat  and 
mouth,  and  the  moist  surfaces  in  and  about  the  genital  tract  in  both 
men  and  women.  The  biological  reason  is  apparent  enough.  Here 
the  germs  find  the  ideal  combination  of  moisture  and  an  absence,  or 
comparative  absence  of  air.  The  constant  friction  and  motion  to 
which  such  surfaces  are  subject  in  walking,  talking,  etc.,  soon  rubs 
the  tops  off  the  spots  in  which  the  germs  have  gathered,  and  releases 
them  by  millions.  The  spot  becomes  covered  with  a  thin  grayish 
membrane,  forming  the  so-called  mucous  patch,  which  with  its 
brother,  the  flat  wart  or  condyloma,  is  by  all  odds  the  most  danger- 
ous sore  produced  by  syphilis.  Mucous  patches  are  practically  pain- 
less. A  throat  may  be  literally  plastered  with  them  from  side  to  side 
and  the  patient  complain  of  no  inconvenience,  or  only  a  slight  sore- 
ness or  discomfort.  There  may  be  none  in  the  throat  but  one  or  two 
of  them  may  appear  on  tlie  under  side  of  the  lip  opposite  the  gum  or 
at  the  angles  of  the  mouth,  ready  to  spread  spirochaetes  over  dishes, 
pipes,  dental  instruments,  the  lips  of  children  or  adults,  the  faces 


70 

and  fingers  of  doctors  operating  on  and  examining  the  mouth,  the 
thermometer  with  which  tlie  nurse  takes  the  temperature.  They  may 
not  be,  and  indeed  too  often  are  not,  seen  by  the  busy  or  hurried 
doctor,  and  certainly  not  by  the  patient,  by  uninitiated  friends  and 
outsiders,  or  by  unsuspecting  wife  and  children.  Similar  spots 
and  patches  appear  about  the  genitals,  but  here  on  account  of  irri- 
tation they  are  inclined,  especially  in  women,  to  grow  into  peculiar 
flat  warts,  or  condylomas.  Growing  about  the  opening  of  the  rec- 
tum they  are  often  mistaken  for  "piles."  Of  all  the  sores  that 
syphilis  can  produce  there  is  nothing  so  rich  in  the  germs  as  the  flat 
wart  or  condyloma.  i!^ot  being  sensitive  they  easily  pass  unnoticed, 
and  one  of  them  can  infect  an  army. 

The  Constitutional  Effects  of  Secondary  Syphilis;  Symptomless 
Syphilis. — It  should  not  be  supposed  that  the  activities  of  secondary 
syphilis  are  limited  to  the  skin  and  the  mucous  surfaces  of  mouth 
and  genitals.  The  spread  of  the  germs  by  the  blood  enables  it  to 
affect  in  some  degree  all  parts  of  the  body.  But  there  is  a  definite 
tendency  on  the  part  of  certain  strains  or  breeds  of  the  Spirochaeta 
pallida  to  affect  some  parts  more  than  others.  Some  patients  de- 
velop the  violent  headaches  of  syphilitic  meningitis  and  nerve 
paralysis  of  various  types.  Others  have  inflammation  in  the  eyes, 
still  others  develop  bone  and  joint  pains  and  swellings  that  too 
often  pass  as  "rheumatism."  Some  have  thinning  of  the  blood 
(anemia)  and  marked  loss  of  weight.  But  the  most  serious  thing 
about  it  all  is  that  many  develop  almost  no  symptoms,  and  occasion- 
ally some  of  them  even  say  they  feel  in  better  health.  Half  the 
persons  with  secondary  syphilis  would  never  have  their  attention 
attracted  to  their  condition  by  their  symptoms.  It  is  indeed  true 
that  those  who  have  a  severe  secondary  syphilis  are  fortunate,  since 
only  too  large  a  share  of  the  victims  pass  untreated  to  the  late 
stages  through  failure  to  realize  that  anything  much  ails  them. 
Treatment  in  the  late  stage  cannot  make  good  damage  that  delay 
through  ignorance  has  made  possible. 


CHAPTER  III. 
RECURRENT,  INACTIVE  AND  LATE  SYPHILIS. 

The  secondary  or  generalized  stage  of  syphilis  terminates  in  a 
i-emarkable  way.  The  billions  of  genns  that  swarm  through  the 
body  when  the  secondary  stage  is  at  its  height,  through  some  re- 
markable development  of  the  patient's  bodily  resistance,  die  out 
whether  the  patient  is  treated  or  not,  until  comparatively  few  re- 
main. But  in  their  dying  they  have  left  behind  a  legacy  that  reaps 
disaster  for  the  victim  of  the  disease  in  his  later  years.  The  body 
has  in  some  way  become  sensitive  to  the  few  germs  that  remain, 
and  as  the  disease  progresses,  reacts  to  their  presence  in  a  far  more 
serious  way  than  it  does  in  the  earlier  stages.  Syphilis  in  the  earh^ 
local  and  in  the  generalized  or  secondary  stage  is  one  of  the  mildest 
of  all  the  serious  infections.  In  its  late  stage  it  becomes  one  of  the 
gravest  diseases  known. 

Latent,  Ohscure  or  Silent,  and  Recurrent  Syphilis. — The  transi- 
tion from  secondary  to  late  syphilis  is  not  abrupt,  not  embraced 
within  a  definite  period  of  time.  Late  manifestations  may  appear 
before  the  chancre  has  thoroughly  healed  in  some  cases.  But  as  a 
rule  they  are  preceded  by  a  period  of  latency,  which  may  last  from 
a  few  weeks  or  months  to  sixty  years  or  more.  In  this  long  period 
of  latency,  in  which  the  patient  is  seldom  reminded  of  the  existence 
of  his  infection,  appear  the  so-called  recurrences  which  make  him  a 
danger  to  his  fellows.  From  time  to  time,  perhaps,  from  some  focus 
or  hiding  place  in  the  body,  it  would  seem  as  if  fresh  showers  of 
germs  may  be  discharged  into  the  blood.  When  these  aifect  the 
constitutional  condition  the  patient  may  note  a  loss  in  weight  and 
feel  under  the  weather,  have  some  aches  and  pains,  and  recover. 
Sometimes  minor  eruptions  appear  on  the  skin,  usually  inconspicu- 
ous and  not  noticed  by  the  patient,  but  highly  significant  to  the 
experienced  physician. 

Contagious  Recurrences  and  Inefficient  Treatment. — When  recur- 
rences affect  the  mucous  membranes  and  the  genital  tract  they 
have  the  most  alarming  meaning  for  the  public  at  large.  They 
usually  take  the  form  of  mucous  patches  and  condylomas,  and  are 
generally  either  not  noticed  by  the  patient  or  are  misinterpreted  as 
cold  sores,  piles,  canker  sores,  smoker's  patches,  etc.  They  swarm 
with  the  germs  of  syphilis,  and  because  unsuspected,  are  doubly  ef- 
fective in  transmitting  the  disease  to  others.  Often  in  the  stage  of 
recurrences,  sores  which  are  not  essentially  syphilitic  will  contain 
the  germs  of  the  disease,  especially  ordinary  cold  sores  (herpes) 
about  the  lips  and  genitals.  It  is  not  difficult  to  grasp  the  fact  that 
a  patient  who  thinks  himself  Avell,  or  does  not  know  that  he  had  the 


72 

disease,  when  armed  with  an  equipment  of  mucous  membrane  recur- 
rences of  whose  presence  he  is  not  aware,  is  an  unconscious  engine 
of  destruction  scarcely  inferioi^  to  a  baby  handling  dynamite. 
Many  an  infection  in  and  out  of  marriage  and  in  the  ordinary  course 
of  life  owes  itself  to  these  fleeting  recurrences  in  syphilitics  who, 
either  in  the  natural  course  of  events  or  after  a  little  treatment, 
recovered  from  their  outspoken  secondary  manifestations.  They 
are  the  Nemesis  for  the  world  at  large,  of  inadequate  treatment. 
Treatment  enough  to  clear  up  a  secondary  eruption  is  not  sufficient 
to  prevent  recurrences.  In  fact  it  is  in  precisely  these  cases  that 
the  recurrence  is  the  greatest  menace,  since  it  catches  patient  and 
doctor  off  his  guard.  I  have  known  patients,  giving  a  frank  history 
of  syphilis  and  of  a  fair  amount  of  modern  treatment  but  not 
enough,  to  be  examined  at  the  hands  of  unusually  competent  gen- 
eral diagnosticians  and  with  normal  or  negative  blood  tests  be 
passed  as  all  right.  Within  twenty-four  hours  after,  I  have  found 
the  Spirochaeta  pallida  in  a  mucous  patch  on  the  tonsil,  which  had 
appeared  literally  over  night.  The  patient,  absolutely  unaware  of 
its  presence  and  secure  in  the  assurances  of  his  physician  of  the 
day  before  to  the  effect  that  he  was  well,  could  scarcely  be  pur- 
suaded  that  he  was  not  the  victim  of  a  hoax. 

Silent  or  Latent  Syphilis  and  Late  Complications. — If  one  adds 
to  the  obscure  and  frequently  overlooked  early  signs  of  syphilis  a 
latent  period  covering  from  ten  to  twenty  years  in  which  absolutely 
nothing  may  warn  the  patient  of  the  fate  that  awaits  him,  it  is  easy 
to  understand  the  almost  mind-destroying  shock  which  temporarily 
wrecks  the  courage  and  morale  of  those  who  in  the  prime  of  life, 
have  to  be  told  that  the  trouble  with  the  stomach,  or  the  pain  in  the 
chest,  or  the  dimming  eyesight  and  unsteady  feet  means  the  syphilis 
of  their  youth. 

''Why,  man,  it  can't  be — I  never  had  a  thing  the  matter  with  me 
in  my  life — never  had  a  sore  or  a  breaking  out,  never  even  had  a 
dose  of  ''clap."  Why  I  haven't  had  to  call  a  doctor  for  twenty 
years,  until  this  came  on.     It  just  can't  be." 

"You  took  your  chances  with  the  rest  when  you  were  a  j^oung 
fellow,  didn't  you,  old  man?" 

"Yes,  I  suppose  I  did,  but  I've  never  been  outside  the  family, 
since  I  married,  doctor;  always  prided  myself  on  being  clean,  and 
yet  you  can  tell  me  this." 

"It  was  somewhere  along  in  there  before  you  married,  old  man, 
even  if  you  didn't  know  it.  Better  bring  the  wife  and  kiddies  up 
to  see  me,  too.    Let's  see,  she  had  two  miscarriages  didn't  she?" 

And  so  the  whole  wretched  story  comes  out  in  dialogue,  each  a 


73 

variation  upon  the  great  central  theme  of  the  latent  period  of 
syphilis. 

Late  Syphilis — Premature  Old  Age  and  Gummatous  Change. — 
Two  changes  characterize  the  activities  of  late  syphilis  in  the  body. 
One  of  these  is  the  induction  of  premature  old  age,  so  to  speak,  by 
the  slow  conversion  of  active  tissue  into  thickened,  hardened,  fibrous 
scar.  The  other  is  the  process  known  as  gummatous  infiltration, 
which  consists  in  the  replacement  of  normal  structure  by  a  kind  of 
tumor-like  growth  of  shoddy  tissue,  which,  being  of  low  vitality, 
breaks  down  or  ulcerates,  leaving  a  hole  to  be  filled  in  its  turn  also, 
by  a  scar.  The  aging  effects  of  syphilis  are  most  apparent  in  the 
blood  vessels  and  in  structures  like  the  heart,  in  which  long-standing 
slight  inflammation  produces  a  hardening,  and  loss  of  elasticity,  a 
toughening  and  thickening  that  finally  impairs  their  power  to  do 
their  work.  Premature  old  age  of  the  arteries,  early  arterioscle- 
rosis, is  common,  and  quite  often,  though  not  always,  due  to  syphilis. 
Gummatous  changes  may  affect  almost  any  structure  of  the  body. 
Since  the  destruction  done  by  gumma  formation  is  permanent  and 
the  tissue  lost  can  only  be  replaced  by  scar,  it  is  a  matter  of  the  ut- 
most import  where  the  gummatous  change  occurs.  Gummas  of  the 
skin  and  bones,  especially  about  the  face,  are  hideous  and  disfiguring, 
but  the  loss  of  a  feature  or  two,  the  caving  in  of  a  nose  or  a  hole  in 
the  roof  of  the  mouth,  is  really  a  cheap  escape  in  late  syphilis.  The 
damage  to  the  goods  in  this  case  involves  the  package  only,  so  to 
speak.  But  gummatous  replacement  of  parts  of  important  organs 
such  as  the  liver  or  the  walls  of  blood  vessels,  large  and  small;  of 
the  tissues  of  the  nervous  system  which  never  regenerate  once  they 
die,  strikes  at  essentials.  As  an  illustration  of  the  often  unsus- 
pected effects  of  such  changes  a  weak  spot  in  the  wall  of  the  lenticulo- 
striate  artery  a  minute  blood-vessel  in  the  brain,  so  often  involved 
in  late  syphilis,  ■  spells  early  apoplexy  for  the  one  whose  disease 
takes  this  form.  As  one  passes  through  the  wards  and  rooms  of 
great  hospitals  one  meets  in  tragic  succession  the  man  whose  wheez- 
ing breath  and  swollen  limbs  and  pounding  heart  betray  the  work 
of  the  Spirocheta  pallida  upon  the  valves  of  his  heart  and  at  the 
base  and  in  the  walls  of  the  aorta,  the  great  artery  that  carries  the 
blood  to  the  body;  the  man  whose  yellow  weazened  pallor,  bony 
chest,  and  enormous  swollen  abdomen  spells  late  syphilis  of  the 
liver;  the  fine  young  fellow  with  the  dark  expressive  but  sightless 
eyes  who  has  gone  the  way  of  "primary  optic  atrophy."  That  thin 
broken  woman  and  those  forlorn  weeping  children  bowed  beside  the 
unconscious  father  whose  loud  puffing  breathing  can  be  heard  all 
along  the  corridor,  are  brought  to  that  death-bed  by  the  work  of 
late  syphilis  upon  the  kidney — "chronic  Bright's  disease"  in  one  of 


74 

its  many  forms.  The  man  whose  feet  flop  wildly  as  he  claws  the 
arms  of  his  wheel-chair  at  your  command  to  rise — the  wobbling, 
doddering  fellow  yonder,  whose  foolish  fatuous  smile  and  trembling 
flabby  lips  and  food-stained  waistcoat  mark  him  as  having  softening 
of  the  brain,  are  part  of  the  picture  of  late  syphilis  at  headquarters, 
among  the  intricate  mechanisms  of  the  nervous  system. 

The  Hopeful  Hide  of  Late  Syphilis. — No  picture  of  late  syphilis 
is  a  just  one,  however,  which  does  not  end  in  reassurance.  Some 
unaccountable  peculiarity  of  the  germ  or  of  the  personal  resistance 
of  the  patient  intervenes  to  save  many  patients  with  syphilis  from 
the  most  distressing  complications  of  the  disease.  Syphilis  is  equal- 
ly adept  in  the  role  of  the  lion  and  of  the  lamb.  On  the  one  hand 
a  gummatous  tumor  of  the  brain  may  carry  off  a  young  fellow  with- 
in a  year  of  his  primary  lesion — on  the  other  hand  an  aged  veteran 
of  the  Civil  War,  may  after  a  latent  period  of  more  than  sixty 
years,  show  a  trivial  little  crusted  sore  or  a  few  small  lumps  in  the 
skin  as  the  sole  remaining  evidence  of  an  infection  that  he  never 
knew  he  had  had,  and  which  never  was  treated.  It  is  impossible 
in  the  present  state  of  knowledge  to  estimate  the  percentage  of  per- 
sons who  having  acquired  the  disease,  later  suffer  from  serious  late 
accidents.  All  that  gan  safely  be  said  is  that  as  our  means  of  de- 
tecting syphilis  in  the  blood,  and  in  the  tissues  and  organs  both 
during  life  and  after  death  become  more  accurate,  our  conception 
of  the  really  tremendous  role  of  this  disease  in  human  disability 
and  phj^sical  deterioration  grows.  One  thing  is  certain ;  if  only  50 
per  cent  of  the  patients  who  contract  syphilis,  die,  or  are  crippled 
with  its  late  complications,  it  ranks  easily  as  one  of  the  most  for- 
midable of  foes — an  enemy  that  no  thinking  human  being  would  in- 
vite within  his  camp  on  the  chance  that  lion  might  prove  lamb. 

Late  Syphilis  of  the  Nervous  System- -Locomotor  Ataxia  and 
General  Paralysis. — The  prevalence  of  locomotor  ataxia  and  of  gen- 
eral paralysis  of  the  insane  needs  a  special  word.  Locomotor  ataxia 
is  a  form  of  creeping  paralysis  of  the  spinal  cord  which  affects  the 
limbs  and  the  nerves  to  the  bladder  usually  first,  but  also  involves 
the  eyes,  and  the  nerve  supply  to  other  structures  including  the 
stomach.  General  paralysis  of  the  insane  or  softening  of  the  brain 
is  a  progressive  and  invariably  fatal  form  of  mental  and  physical 
degeneration  which  converts  the  victim  from  a  normal  individual 
into  an  imbecile  and  a  skeleton  before  his  death.  These  two  dis- 
eases constitute  to  the  partly  informed  public  and  to  victims  of 
syphilis,  the  overwlielmiug  horror  of  their  outlook.  The  l)elief  that 
all  syphilitics  are  doomed  creatures,  certain  to  lose  the  use  of  their 
limbs  or  their  mental  faculties  is,  however,  wholly  wrong.  It  is 
not  at  all  improbable  that  as  high  as  10  or  15  per  cent  of  syphilitics 


75 

show  changes  in  the  nervous  system  which  are  due  to  the  disease,  but 
in  many  cases  these  changes  do  not  progress,  and  may  even  fail  to 
attract  attention.  Estimates  of  the  prevalence  of  these  two  dis- 
eases vary  from  1  to  6  per  cent  of  the  total  number  who  acquire 
syphilis,  figures  which  make  it  evident  they  are  by  no  means  the 
inevitable  termination  of  a  syphilitic  infection.  Persons  with 
syphilis  are  predisposed  to  these  complications  by  bad  habits  of  liv- 
ing as  well  as  peculiarities  in  the  germ  and  the  resistance  of  the 
patient,  so  that  much  can  be  done  by  the  syphilitic  himself  to  escape 
the  fate  they  bear. 

Late  Syphilis  is  Preventable  and  Treatable. — Another  word  of 
reassurance  must  accompany  any  discussion  of  late  syphilis.  It  is 
both  preventable,  and  treatable.  While  both  these  points  will  be 
better  understood  after  the  discussion  of  treatment  in  general,  it 
may  be  emphasized  here,  that  adequate,  skilled  modern  treatment 
can  reduce  the  danger  of  developing  the  late  complications  of  the  dis- 
ease, almost  to  the  vanishing  point.  In  fact,  the  mortality  of  only 
moderately  well  treated  syphilis  is  much  lower  than  that  of  most 
serious  diseases.  The  ability  of  good  treatment  in  the  latent  period, 
largely  to  forestall  the  real  terrors  of  the  disease,  even  in  cases  which 
have  been  recognized  comparatively  late,  offers  abundant  hope  to 
the  victims  in  this  generation.  Even  in  still  later  cases  which 
show  the  unmistakable  signs  of  serious  changes  in  important  organs 
and  in  the  nervous  system,  a  prompt  resort  to  systematic  measures 
may  repair  a  good  deal  of  damage  and  fight  off  the  enemy  for  an 
average  lifetime.  But  even  while  we  recall  the  hope  for  the  victims, 
let  us  never  forget  that  the  real  strategy  in  our  battle  with  syphilis 
must  be  that  of  prevention,  and  that  the  abortive  cure,  and  early 
systematic  treatment  have  a  worth  that  no  amount  of  scientific 
patching  and  repair  work  can  ever  claim.  The  treatment  of  the 
chancre  in  the  first  few  days  of  its  existence  is  the  treatment  of 
meningoencephalitis  and  tabes  dorsalis,  of  cirrhosis  of  the  liver,  of 
syphilitic  myocarditis  and  coronary  sclerosis,  of  aortitis  and  aneur- 
ism, of  primar}^  optic  atrophy  and  internal  ear  deafness,  and  all 
that  roll  call  of  strange  names  which  blaze  the  path  of  syphilis 
across  the  field  of  medicine. 


76 

CHAPTER  IV. 
MODERN  TESTS  FOR  THE  RECOGNITION   OF  SYPHILIS. 

Lahoratory  Tests  vs.  Medical  Examination  in  Syphilology. — In  a 
broad  way  it  may  be  said  that  the  criterion  which  distinguishes  the 
medicine  of  the  past  from  that  of  the  present,  is  the  dominance  of 
the  laboratory  in  the  modern  recognition  and  treatment  of  disease. 
In  no  field  has  this  revolutionary  power  done  its  work  more  thor- 
oughly or  to  greater  advantage  than  in  the  field  of  syphilis.  Fif- 
teen years  have  seen  the  entire  situation  with  respect  to  the  disease 
transformed  almost  beyond  recognition  as  compared  with  a  genera- 
tion ago.  In  this  transition  four  landmarks  stand  out  conspicu- 
ously as  mileposts  in  the  general  advance. 

The  first  was  reached  when  Wassermann,  Neisser  and  Bruck  an- 
nounced in  1904  the  successful  application  to  the  diagnosis  of  syph- 
ilis, of  a  test  made  upon  the  blood  of  the  patient.  This  test  is  based 
upon  the  work  of  two  French  investigators,  Bordet  and  Gengou,  and 
has  wide  applicability  outside  of  the  immediate  field  of  syphilis, 
although  in  no  disease  has  its  service  been  more  gratifying  or  more 
spectacular.  The  blood  test  for  syphilis  is  now  quite  generally 
known  as  the  Wassermann  test.  The  second  landmark  of  progress, 
in  chronological  order,  is  the  discovery  of  the  germ  causing  the  dis- 
ease, by  Schaudinn  and  Hoffmann  in  1905.  The  tremendous  signifi- 
cance of  this  discovery  for  the  recognition  of  syphilis  in  the  earliest 
days  of  its  onset,  when  radical  and  complete  cure  is  possible,  cannot 
be  overestimated.  The  method  of  its  application  in  the  use  of  the 
darkfield  microscope  has  already  been  discussed.  It  has  a  third 
field  of  usefulness  which  bids  fair  to  grow  into  greater  prominence 
with  time — the  identification  of  the  germ  in  the  tissues  of  the  body 
after  death.  This  will  serve  as  the  ultimate  check  upon  our  con- 
ceptions of  the  curability  and  the  real  prevalence  of  the  disease. 
In  fact  it  is  the  identification  of  the  Spirocheta  pallida  in  the  tissues 
of  the  brains  and  spinal  cords  of  patients  dying  of  general  paralysis 
and  locomotor  ataxia,  by  Noguchi  and  Moore  in  1913,  that  first 
proved  beyond  reasonable  doubt,  the  syphilitic  nature  of  these  com- 
plications. From  the  first  landmark,  the  Wassermann  test,  as  ap- 
plied to  the  study  of  the  nervous  system,  has  arisen  a  third  valuable 
diagnostic  aid,  the  study  of  the  spinal  fluid  in  syphilis  as  a  means 
of  recognizing  early  invasion  of  the  nervous  system  by  the  germ. 
The  fourth  contribution  to  modern  warfare  against  the  disease 
based  on  the  discovery  of  the  germ,  is  the  development  of  the  drug 
known  as  ''G06,"  dimethyl-diamino-arsenobenzol-dihydrocliloride, 
which  is  a  vital  part  of  our  modern  program  for  the  control  of  in- 
fection and  the  early  cure  of  the  disease. 


Y7 

The   Wasscrmmin  Blood   Test   for  Syphilis. — The  Wassermann 
blood  test  for  syphilis  is  based  upon  the  general  observation  that 
when  the  body  is  invaded  by  certain  germs,  it  develops  a  defensive 
mechanism  which  takes  the  form  of  the  appearance  in  the  blood  of 
substances  that  poison  or  cripple  the  invaders,  or  in  some  less  defi- 
nite way,  make  conditions  unfavorable  for  them.     In  the  case  of  cer- 
tain diseases,  the  relation  betAveen  the  invading  germ,  such  as  the 
diphtheria  bacillus,  and  the  substance  produced^  by  the  body  for  de- 
fensive purposes,  is  obvious  and  direct.    The  antitoxin  of  diph- 
theria combines  with  and  destroys  the  poison  of  the  diphtheria  germ, 
as  one  chemical  combines  with  another,  to  neutralize  it.     On  the 
other  hand  in  certain  other  germ  diseases  the  body's  method  of  at- 
tack is  less  obvious  and  simple.    The  finding  in  the  blood  of  sub- 
stances known  to  bear  a  fixed  relation  to  the  presence  of  certain 
disease  germs  in  the  body  serves  as  a  means  of  identifying  the  dis- 
ease in  a  particularly  doubtful  case.    An  analogy  to  the  employment 
of  blood  tests  in  the  detection  of  disease  might  be  found  by  picturing 
the  physician  in  the  situation  of  a  deaf,  dumb  and  blind  man  wand- 
ering across  a  field  of  battle.     Knowing  that  mustard  gas  is  used  in 
modern  warfare,  he  would  upon  getting  a  whiff  of  it,  infer  that  he 
was  near  or  upon  the  scene  of  a  battle.     It  is  of  course  possible, 
however,  that  he  might  instead  be  near  the  laboratory  of  a  chemical 
works  where  the  gas  was  being  made.    When  he  identifies  the  gas 
by  his  sense  of  smell,  he  must  go  through  a  course  of  reasoning, 
brief  though  it  may  be,  in  which  he  will  estimate  the  chance  of  be- 
ing misled  by  the  fact  that  the  gas  may  be  in  a  laboratory  and  not 
on  the  field  of  battle.    Being  deaf,  he  cannot  hear,  but  he  may  feel 
the  ground  heave  beneath  his  feet,  and  feel  the  air  tremble  with  the 
detonations^  of  guns.     Correlating  these  additional  impressions  he 
will  further  be  convinced  that  he  is  not  in  a  laboratory,  but  at  the 
scene  of  a  gas  attack  on  the  field  of  battle.    Precisely  such  a  com- 
plex chain  of  reasoning  applies  to  the  recognition  of  a  disease  by  a 
blood  test.    The  spirochaete  of  syphilis,  under  certain  conditions  in 
the  animal  body,  produces  changes  which  manifest  themselves  by  the 
presence  of  certain  substances  in  the  blood.     These  substances  are 
not  anti-toxins  or  chemicals  which  react  directly  with  the  germ. 
They  may  even  be  the  products  discharged  into  the  blood  by  the 
death  of  the  germs  in  their  fight  with  the  body.     But  under  certain 
conditions,  which  constitute  the  limitations  of  accuracy  of  the  test, 
the  presence  of  these  substances  shows  the  germs  of  syphilis  to  be 
present.     Precisely  as  in  the  case  of  the  man  who  smells  mustard 
gas,  it  is  necessarj'^  for  us  after  proving  their  presence  to  reason 
whether  or  not  some  factor  may  not  be  obscuring  the  test  by  con- 
cealing the  expected  substance  when  it  should  be  there,  or  to  decide 


78 

whether  it  is  not  there  for  some  other  reason  than  because  syphilis 
is  present.  Both  these  factors  enter  into  the  accuracy  of  the  blood 
test  for  syphilis,  and  into  the  interpretation  of  the  information 
which  it  gives  us.  In  other  words,  the  finding  of  syphilitic  sub- 
stances in  the  blood  of  a  person  is  simply  one  factor  in  the  chain 
of  reasoning  which  must  be  carried  through  in  every  case  before  we 
can  say  positively  that  the  presence  of  those  substances  means  the 
person  has  syphilis.  Under  these  circumstances  it  is  apparent  that 
the  test  falls  far  short  of  infallibility,  and  that  a  blunder  in  the 
reasoning  of  the  doctor  who  Interprets  it,  or  a  gap  in  his  experience 
is  quite  as  important  in  making  the  test  worthless  as  is  an  actual 
error  in  its  performance. 

Personal  Equation  and  Interpretation  in  the  Wassermann  Test. — ■ 
The  mechanism  of  the  Wassermann  test  is  too  complex  for  the  com- 
prehension of  the  average  layman  without  an  amount  of  detailed 
discussion  that  would  be  out  of  place  here.  It  may  be  said  of  it  in 
general,  and  in  fact  of  every  complement  fixation  reaction  as  this 
type  of  test  is  called,  whether  in  syphilis,  gonorrhea,  tuberculosis  or 
elsewhere,  that  its  accuracy  depends  upon  the  technical  skill,  experi- 
ence, and  judgment  of  the  one  who  performs  it.  Wassermann  tests 
are  constantly  being  performed  which  are  valueless  and  the  desti- 
nies of  human  beings  are  being  decided  on  laboratory  evidence  which 
is  not  worth  the  paper  on  which  the  report  is  written.  On  the 
other  hand,  the  Wassermann  test,  performed  by  an  expert  of  large 
experience  and  high  standing,  and  interpreted  to  the  patient  by  a 
physician  who  knows  syphilis,  is  one  of  the  most  valuable  tests  in 
medicine,  and  has  a  margin  of  error  that  is  very  small.  Between 
these  two  extremes,  one  finds  in  actual  practice  every  conceivable 
grade  of  understanding  and  misunderstanding,  of  efficiency  and 
worthlessness. 

The  Positive  Wassermann  Test. — When  the  Wassermann  test  on 
the  blood  shows  the  presence  of  the  disease,  it  is  spoken  of  as  posi- 
tive, usually  strongly  positive.  When  it  does  not  show  the  pres- 
ence of  the  disease,  it  is  spoken  of  as  negative.  "Doubtful''  usually 
means  a  test  of  no  value  either  way.  Certain  well-defined  limits 
are  set  upon  the  value  of  the  Wassermann  test  in  the  recognition  of 
the  presence  of  syphilis.  First  of  all,  the  test  may  be  positive,  but 
is  rarely  so,  in  other  diseases  in  temperate  climates.  In  the  tropics 
a  rather  common  disease  called  "yaws''  gives  a  positive  Wassermann 
test.  The  margin  of  error  on  the  positive  side  is  small — in  other 
words,  a  competently  performed  Wassermann  test  in  the  temperate 
zone,  if  positive,  means  syphilis  in  95  to  98  per  cent  of  case?.  On 
rhe  other  hand,  the  situation  is  radically  different  with  the  negative 
test. 


79 

The  Negative  Wassermaim  Test. — A  iiegati\e  Wassermanu  test 
even  when  technically  correct  does  not  prove  the  absence  of  syphilis. 
A  negative  test  while  rare  in  secondar}^  syphilis  occurs  naturally 
in  as  high  as  35  per  cent  of  syphilitics  in  the  later  stages  of  the 
disease,  and  in  all  syphilitics  during  the  first  few  days  of  the  pri- 
mary sore,  at  which  time  the  precious  hope  for  radical  or  abortive 
cure  exists.  Therefore  a  doctor  who  depends  on  the  Wassermann 
test  to  tell  him  when  he  is  dealing  with  syphilis,  will  miss  all  of 
his  cases  at  the  time  when  the  prospect  of  curing  them  is  at  its 
best,  and  will  miss  a  liberal  percentage  of  them  late  in  the  disease 
when  it  is  vitally  important  they  be  recognized  before  the  damage 
has  gone  too  far  for  recovery. 

Effect  of  Treatment  on  the  Blood  Test. — Treatment  for  syphilis 
has  the  power  to  make  a  positive  Wassermann  test  negative.  The 
amount  of  treatment  needed  to  make  a  positive  test  negative  may 
be  much,  or  exceedingly  little.  Unless  treatment  in  a  patient  with 
syphilis  has  been  carried  to  the  point  which  experience  has  shown 
us  is  necessary  for  arrest  or  cure,  the  test  may  not  remain  negative. 
It  may  become  positive  again  within  a  few  weeks  or  months  after 
treatment  is  stopped.  Even  if  it  does  remain  negative  the  disease 
may  go  on  working  just  the  same.  A  Wassermann  test  may  be 
negative  on  the  blood  for  years,  and  the  patient  die  of  sj^philitic 
heart  disease  or  of  changes  in  his  nervous  system.  A  Wassermann 
may  become  negative  on  the  blood  for  a  few  months  after  insuf- 
ficient treatment,  and  the  patient  then  marry,  only  to  infect  his  wife 
while  his  own  blood  still  remains  negative.  The  germs  of  syphilis 
can  be  taken  from  a  mucous  patch  on  the  lip  of  a  patient  while  his 
blood  test  is  negative.  They  can  even  be  grown  from  his  blood 
while  his  blood  shows  no  signs  of  syphilis  that  a  Wassermann  test 
will  detect.  When  all  this  unescapable  evidence  of  the  shortcom- 
ings of  the  negative  Wassermann  test  is  taken  into  account,  one 
may  well  ask,  of  what  use  it  is  anyhow.  'In  reply  to  this  question, 
only  one  thing  can  be  said.  One  negative  or  two  negative  Wasser- 
mann blood  tests  mean  nothing  at  all.  In  the  presence  of  a  reason 
for  suspecting  the  disease,  only  a  series  of  negative  tests  can  mean 
anything  as  a  proof  of  its  absence.  In  a  patient  treated  for  syphilis, 
the  series  of  negative  tests  must  extend  consistently  over  months 
and  years,  and  even  then  it  is  not  trustworthy  unless  the  most 
searching  examination  of  every  accessible  structure  of  the  body 
shows  that  the  disease  is  not  in  hiding.  The  Wassermann  blood 
test  for  syphilis  has  no  infallibilities.  It  is  merely  a  part  of  a  chain 
of  reasoning,  and  its  value  is  dependent  not  only  upon  the  skill  of 
the  performer,  but  upon  that  of  the  reasoner. 


80 

the  General  Medical  Examination  Essential. — With  this  proviso, 
the  syphilis  of  the  examining  room  again  claims  its  place,  so  long 
threatened  by  the  syphilis  of  the  laboratory.  An  opinion  as  to 
whether  or  not  a  person  has  syphilis,  or  having  had  it,  has  recovered, 
cannot  be  based  upon  a  blood  test.  It  depends  in  the  last  analysis 
upon  what  the  physician  who  renders  the  opinion,  knows  about 
every  aspect  of  syphilis.  So  few  and  far  between  are  the  men  who 
know  the  ramifications  and  intricacies  of  the  disease,  that  critical 
judgments  can  best  be  rendered  by  a  group  of  physicians,  perhaps 
under  the  leadership  of  one  who  has  made  the  disease  a  special  and 
lifelong  study.  In  other  w^ords,  the  eye  specialist  and  the  ear  spe- 
cialist, the  expert  on  diseases  of  the  nervous  system  and  the  clinician 
who  knows  the  heart,  the  specialist  on  the  diseases  of  the  bones,  the 
expert  on  the  skin,  each  may  have  his  place  beside  the  laboratory 
man  with  his  dark  field  and  Wassermann  test.  No  one  of  them  can, 
without  presumption,  claim  that  his  assertion  that  there  is  no  sign 
of  syphilis  in  the  particular  part  of  the  body  which  he  knows, 
proves  there  is  none  elsewhere  in  the  system.  To  laboratory  meth- 
ods we  must  concede  almost  unqualified  title  to  first  place  in  the 
recognition  of  syphilis  by  the  finding  of  the  germ  in  the  chancre, 
in  recurrent  sores  on  mouth  and  genitals,  and  in  the  confirmation  of 
the  presence  of  syphilis  in  the  secondary  stage,  when  the  Wasser- 
mann test  w'ell  performed  is  positive  in  practically  one  hundred 
per  cent  of  cases.  To  clinical  facts  as  ascertained  by  a  careful  gen- 
eral physical  examination  we  must,  however,  as  the  last  resort  look 
for  final  judgment  where  the  laboratory  tests  are  disappointing  or 
inconsistent. 

Spinal  Fluid  Tests. — The  examination  of  the  spinal  fluid  by  the 
aid  of  the  Wassermann  test  has  developed  rapidly  in  importance  in 
recent  years.  The  spinal  fluid  is  a  watery  clear  liquid  that  sur- 
rounds and  supports  the  brain  and  spinal  cord  inside  the  skull  and 
spinal  column,  acting  as  a  sort  of  water  cushion  to  protect  them 
against  shock.  This  fluid,  in  syphilitic  disease  of  the  nervous  sys- 
tem, undergoes  changes  which  prove  the  presence  and  help  to  iden- 
tify the  seriousness  and  extent  of  the  damage  done  by  the  disease 
in  the  tissues  of  the  nervous  system,  even  when  all  other  signs  fail 
or  leave  one  puzzled  as  to  what  is  going  on.  The  testing  of  the 
spinal  fluid  is  often  a  necessary  adjunct  to  the  blood  test  in  settling 
the  question  of  the  presence  or  absence,  or  the  cure  of  syphilis,  and 
as  such  it  will  attain  to  constantly  greater  usefulness. 

Both  the  Wassermann  blood  test  and  the  examination  of  the  spinal 
fluid  are  at  their  best  when  performed  by  hospitals  and  by  groups  of 
specialists  who  have  the  means  at  hand  to  make  them  properly  and 
interpret  them  correctly  to  the  patient.     The  drawing  of  blood  for 


81 

the  Wassermann  test  is  a  trifling  matter,  and  can  be  done  by  almost 
anyone.  The  popularity  of  the  test  has  made  many  physicians  un- 
critical in  regard  to  it,  and  has  encouraged  the  growth  of  labora- 
tories whose  tests  have  all  the  faults  and  inaccuracies  which  the 
peculiarities  of  the  Wassermann  reaction  make  possible.  Until  the 
situation  is  finally  standardized,  perhaps  by  government  control, 
the  Wassermann  test  will  be  abused  and  misinterpreted.  The  sound 
est  advice  that  in  the  present  state  of  knowledge  can  be  given  one 
who  has  reason  to  ask  himself  if  he  has  syphilis,  is  "to  seek  expert 
medical  advice,"  rather  than  "to  have  a  Wassermann  taken." 


82 

}/  CHAPTER  V. 

HEREDITARY  SYPHILIS. 

Effect  of  Byphilis  on  the  Race. — ^We  must  now  take  up  an  aspect 
of  syphilis  which  makes  it  all  but  unique  among  diseases,  namely, 
its  transmission  to  the  second  generation.  Gonorrhea  affects  the 
future  of  the  race  by  making  men  and  women  childless.  Syphilis 
affects  the  race  by  destroying  outright  75  per  cent  of  the  children 
of  syphilitic  parents  before  they  are  born  or  during  the  first  year 
of  life,  and  by  crippling  or  weakening  a  considerable  proportion 
of  those  who  survive.  Gonorrhea  as  such  is  not  transmissible  to 
the  child  before  birth.  On  the  other  hand,  syphilis  is  more  often 
transmitted  in  this  way  than  otherwise,  and  when  so  transmitted  is 
not  mere  constitutional  inferiority,  but  syphilis,  as  definite  and 
actual  as  if  acquired  with  a  chancre  and  secondary  period  dur- 
ing later  life. 

"  The  SyjJhilitic  Mother. — A  very  large  body  of  evidence,  much  of 
which  has  come  into  existence  since  the  Wassermann  test  was  de- 
vised, has  shown  that  in  the  great  majority  of  cases,  syphilis  is  trans- 
mitted to  the  child  by  its  mother,  rather  than  by  its  father.  This 
means  that  the  role  of  the  father,  if  he  be  responsible,  is  in  the  in- 
fection of  the  mother.  It  is  only  fair  to  say  that  this  question  of 
paternal  transmission  is  not  wholly  settled,  and  that  there  are  able 
men  who  believe  that  the  father  can  be  responsible  for  the  infection 
of  the  unborn  child  without  infecting  the  mother.  It  is,  however, 
the  general  opinion  that  a  child  syphilitic  at  birth,  means  a  mother 
with  syphilis,  whether  or  not  she  shows  outward  signs.  In  fact, 
the  mother  sometimes  shows  no  signs  of  the  disease  to  either  exami- 
nation or  blood  test,  a  condition  theoretically  explained  by  her  hav- 
ing developed  a  form  of  immunity  through  carrying  the  child.  The 
presumption,  however,  is  that  she  has  the  disease  and  should  there- 
fore be  treated  for  it. 

Mode  of  Infection  of  the  Child. — Children  may  acquire  syphilis 
before  birth,  through  the  transfer  of  the  germs  from  the  body  of 
the  mother  to  the  blood  of  the  child,  through  the  placenta,  the  struc- 
ture which  connects  the  child  with  the  wall  of  the  womb.  If  the 
child  acquires  syphilis  through  the  mother's  blood  within  the  first 
three  months  after  conception  it  is  almost  certain  to  die  and  the 
body  be  expelled,  constituting  an  abortion  or  miscarriage.  If  it 
acquires  syphilis  from  the  third  to  the  seventh  month,  it  may  sur- 
vive for  a  time,  but. is  likely  to  be  born  prematurely  and  very  prob- 
ably dead.  If  it  is  not  infected  until  after  the  seventh  month  of  pre- 
natal life,  it  will  probably  be  born  alive,  although  it  may  die  later 
of  the  disease.     The  time  after  conception  that  a  child  in  the  womb 


83 

is  likely  to  be  infected  varies  to  a  certain  extent  with  the  activity 
and  age  of  the  mother's  infection.  If  she  has  been  recently  infected, 
and  there  are  still  many  germs  in  her  body  and  frequent  showers 
of  them  circulating  in  her  blood,  the  child  has  almost  no  chance 
of  escape.  The  result  is  miscarriage  or  abortion,  repeated  again 
and  again  whenever  the  woman  becomes  pregnant.  Some  of  these 
abortions  occur  so  early  that  the  woman  may  think  she  is  simply 
suffering  from  irregular  menstruation.  As  the  mother's  infection 
becomes  older  and  less  virulent,  the  child  is  not  infected  until  later 
in  the  pregnancy,  or  may  even  escape  altogether.  It  may  die  if  in- 
fected, resulting  in  a  still  birth,  or  it  may  live  and  show  its  first 
signs  in  the  first  few  months  after  birth.  Again,  it  may  live,  seem 
in  fair  health,  and  show  no  signs  of  the  disease  until  it  is  from  five 
to  ten  years  old.  A  few  cases  do  not  show  any  signs  until  much 
later,  even  as  old  as  twenty-five  years. 

Treating  the  Mother  May  Protect  the  Unborn  Child. — No  fixed 
rule  applies  to  the  birth  of  syphilitic  children  from  a  mother  who 
has  the  disease,  although  usually  a  series  of  abortions  is  followed 
by  a  still  birth  or  two  and  finally  by  living  but  syphilitic  children, 
as  the  activity  of  the  mother's  infection  subsides.  A  syphilitic 
mother  whose  disease  has  been  temporarilj'^  reduced  to  inactivity 
by  treatment  in  the  later  stages  may  give  birth  to  an  entirely  healthy 
child,  and  wofnen  who  still  have  active  syphilis  may  occasionally 
have  children  who  escape.  Even  a  woman  who  is  in  the  secondary 
stage  of  syphilis,  whose  pregnancy  is  recognized  in  time  may  ap- 
parently give  birth  to  a  healthy  child  if  she  is  intelligently  and  sys- 
tematically treated  for  syphilis  herself  all  during  the  period  she 
is  carrying  the  child.  Once  again,  a  woman  who  acquires  syphilis 
just  before  the  child  is  to  be  born,  and  who  has  a  chancre  or  mucous 
patches  on  the  neck  of  the  womb  or  in  the  vaginal  birth  canal,  may 
give  birth  to  a  healthy  child  whom  she  infects  as  she  brings  it  into 
the  world.  This  variety  of  syphilis  in  children  is  comparable  to 
birth  infection  with  gonorrhea  and  is  true  congenital  as  distin- 
guished from  uterine  sj^philis.  It  runs  the  same  course  as  the  adult 
form,  with  a  chancre,  often  on  the  navel,  and  a  secondary  eruption 
as  in  the  acquired  case. 

Effect  of  Inherited  Sijphilis  on  the  Child. — Uterine  syphilis  in 
the  child  gives  rise  to  changes  in  its  body  which  are  more  profound 
than  those  which  occur  from  the  acquired  form.  The  child  being  lit- 
erally filled  with  the  germs  as  it  is  coming  into  being,  is  distorted  to 
some  extent  by  the  disease.  Changes  in  the  bones,  in  the  teeth,  and 
in  the  internal  organs  occur  which  have  much  in  common  with  late 
syphilis.  But  if  the  child  does  not  die  outright  before  or  within 
a  year  or  two  after  birth,  the  intimate  association  of  its  body  cells 


84 

with  the  germs  gives  them,  paradoxically,  an  advantage.  Such  chil- 
dren must  have  a  high  resistance  or  they  would  die.  For  this  rea- 
son, children  with  uterine  syphilis  after  the  first  high  mortality, 
have  an  excellent  fighting  chance,  wliicli  if  reinforced  ly  intelligent 
treatment^  may  permit  them  to  develop  into  practically  normal 
men  and  women. 

Symptoms  of  Syphilis  in  the  New-Born. — Children  with  syphilis 
who  are  born  alive,  sometimes  seem  outwardly  normal  at  birth. 
Quite  a  number  of  them  die,  however,  soon  after  birth  from  con- 
vulsions and  other  internal  ailments.  As  a  rule,  however,  the  syph- 
ilitic child  presents  at  birth  a  striking  example  of  the  power  of  the 
germ  of  syphilis  to  age  the  human  body.  The  child  looks  weazened, 
withered,  so  to  speak,  at  the  root.  The  face  suggests  a  little  old 
man,  the  child  is  under  size,  and  within  a  few  days  or  weeks  of 
birth  begins  to  show  outspoken  signs  of  the  disease  in  the  form 
of  "snuffles"  or  running  nose,  often  taken  for  a  cold,  and  changes 
in  the  vocal  mechanism  which  convert  the  normal  cry  into  a  squawk. 
Skin  eruptions  especially  large  blisters,  mucous  patches,  and  large 
sores  may  appear,  and  unless  treated,  the  child  rapidly  declines. 
Extraordinary  variations  in  the  picture  presented  by  syphilis  in  the 
child  may  occur.  Not  every  child  with  a  skin  rash  and  a  feeble  cry 
is  syphilitic.  On  the  other  hand,  it  is  a  wise  caution  that  sends 
the  mother  or  the  woman  in  charge  of  sickly  children  to  the  doctor 
when  something  abnormal  develops,  and  it  is  a  wiser  caution  that 
keeps  healthy  women  from  meddling  with  others'  sick  children  until 
they  are  properly  advised  by'  a  competent  physician.  A  caution 
may  well  be  given  here  also  with  reference  to  the  wet  nurse,  who 
should  never  take  up  the  care  of  a  child  except  under  the  direction  of 
an  expert  physician  who  can  protect  her  from  the  risk  of  nursing 
a  syphilitic  baby  who  will  promptly  transmit  the  disease  to  her. 
Vice  versa  there  is  no  better  way  to  infect  a  well  baby  than  to  give 
it  to  a  syphilitic  woman  to  nurse.  Fortunately  the  best  modern 
technic,  which  simply  draws  the  woman's  milk  and  feeds  it  to  the 
baby  after  proper  sterilization  will  reduce  the  risk  of  such  trans- 
mission of  the  disease.  There  is  no  better  evidence  that  the  mother 
of  a  syphilitic  child  has  syphilis,  than  the  fact  that  she  cannot  ac- 
quire it  from  her  own  nursing  baby  even  though  the  baby  has  a 
mouth  full  of  mucous  patches. 

-  Late  Effects  of  Inherited  Syphilis;  ImheciUty,  Eye  and  Eai* 
Trouble. — Uterine  syphilis  in  older  children  may  repeat  the  course 
of  syphilis  acquired  in  adult  life,  even  to  the  development  of  juve- 
nile locomotor  ataxia  and  general  paresis.  On  the  other  hand,  it 
has  some  distinctive  features.  About  five  per  cent  of  children  who 
are  idiotic  are  so  because  of  syphilis.     Many  syphilitic  children 


85 

show  distinctive  changes  in  the  teeth  and  certain  bones,  which  can 
be  recognized  even  though  the  Wassermann  test  may  be  and  fre- 
quently is  negative.  While  the  large  majority  of  syphilitic  children 
are  below  par  physically,  it  often  seems  as  if  they  had  a  precocious 
mental  development  not  unlike  that  seen  with  rickets,  which  makes 
them  by  no  means  degenerates,  but  valuable  assets  in  human  life 
once  their  infection  is  brought  under  control  by  treatment.  Heredo- 
syphilitic  children  are  subject  to  a  peculiar  type  of  eye  trouble, 
called  interstitial  keratitis,  which  clouds  the  cornea  or  glassy  part 
of  the  eye  so  that  not  over  60  per  cent  of  the  cases  which  have  it 
recover  with  vision  unimpaired.  Many  of  these  children  lose  their 
ability  to  earn  a  living  and  become  burdens  upon  the  family,  the 
community  and  the  state.  A  few  children  are  made  totally  blind 
by  syphilitic  changes  in  the  nerve  of  sight.  A  similar  but  much 
commoner  type  of  change  occurs  in  the  nerve  of  hearing,  resulting 
in  total  and  irremediable  deafness.  In  the  infant  it  is  recognized 
by  the  child's  failure  to  learn  to  speak,  and  if  it  develops  before 
the  tenth  year  the  child  is  likely  to  become  dumb,  either  because 
it  does  not  learn  or  forgets  how  to  talk.  The  inmates  of  deaf  and 
dumb  asylums  and  schools  present  in  all  probability  a  high  pro- 
portion of  heredo-syphilitics,  although  just  what  proportion  is  not 
known. 

Hereditary  Syphilis  and  the  Third  Generation. — One  or  two  ad- 
ditional points  deserve  mention.  Hereditary  syphilis  in  the  strict 
sense  is  probably  not  transmitted  to  offspring— that  is  the  children 
of  hereditary  syphilitics  do  not  have  abortions  and  give  birth  to 
syphilitics  as  do  their  parents.  On  the  other  hand  there  is  room  for 
disagreement  on  this  point,  and  able  men  again  believe  that  the 
germ  may  be  handed  on  for  more  than  two  generations.  It  is  gen- 
erally'" conceded  that  a  tendency  to  constitutional  inferiority  ap- 
pears in  the  children  of  parents  who  have  severe  forms  of  heredi- 
tary syphilis.  Those  who  have  hereditary  syphilis  in  mild  form, 
however,  may  if  efficiently  treated,  give  birth  to  healthy  children. 

Public  Responsibility  in  Hereditary  Syphilis. — Syphilis  in  adopted 
or  orphaned  children  should  be  much  more  a  matter  of  concern  on 
the  part  of  the  state  than  it  is.  Careful  Wassermann  tests  on  moth- 
er, father  and  child  should  be  available  in  every  baby  offered  for 
adoption,  and  the  risk  of  a  concealed  infection  will  be  diminished 
if,  where  there  is  doubt,  adoption  is  deferred  until  after  the  second 
year.  Children  who  prove  early  or  later  in  their  lives,  to  have  the 
disease,  should  not  be  offered  for  adoption,  but  should  be  cared  for 
and  treated  by  the  state.  The  contagiousness  of  hereditary  syphilis 
and  its  treatment  will  be  discussed  in  connection  with  these  aspects 
of  the  disease  as  a  whole. 


86 

CHAPTER  VI. 
THE  TREATMENT  OF  SYPHILIS. 

From  the  standpoint  of  treatment,  as  in  other  ways  that  have 
been  mentioned,  syphilis  occupies  a  distinctive  place  in  the  hier- 
archy of  disease.  In  the  domain  of  general  medicine  there  is  a 
small  group  of  ailments  Avhose  successful  treatment  presents  the 
dramatic  and  spectacular  quality  that  makes  surgery,  for  instance, 
so  attractive  to  the  majority  of  physicians.  Malaria  is  the  oldest 
member  of  this  group.  The  control  of  malaria  by  quinine  is  a 
medical  miracle  which  never  loses  its  power  to  astonish  because  it 
is  so  familiar.  In  the  same  way,  the  control  of  syphilis  by  the  drugs 
both  ancient  and  modern  which  are  used  against  it,  contains  all 
the  dramatic  elements  that  add  zest  to  the  work  of  him  who  treats 
it  and  give  hope  to  those  who  look  for  its  ultimate  extermination. 
The  treatment  of  syphilis  has  what  the  treatment  of  gonorrhea 
lacks,  weapons  whose  efficiency  stands  all  but  unrivalled  in  the 
practice  of  the  healing  art. 

The  Treatment  of  Syphilis  with  Mercury. — Mercury  throughout 
the  five  centuries  intervening  since  the  wholesale  spread  of  syphilis 
over  the  world  has  sustained  much  the  same  relation  to  the  disease 
that  quinine  has  to  malaria.  The  ability  of  this  drug  to  cause  the 
outward  signs  of  the  disease  to  vanish  was  early  recognized,  and  its 
Avholesale  and  over-enthusiastic  use  for  a  time  threatened  to  retire 
it  to  obscurity  rather  than  to  develop  its  effectiveness.  Mercury  is 
a  poison,  and  gives  rise  to  symptoms  at  times  only  less  serious  than 
the  disease  itself.  In  fact  it  acts  only  by  being  more  poisonous  for 
the  germs  than  for  the  tissues  of  the  body  itself.  For  that  reason 
its  proper  use  was  .only  slowly  developed,  and  its  limitations  are 
set,  not  so  much  by  the  fact  that  more  would  not  kill  spirochetes 
more  effectively,  but  that  more  might  kill  the  patient.  While  the 
action  of  the  drug  in  the  body  is  usually  thought  of  as  directly  upon 
the  germs,  it  seems  very  prol)able  that  while  this  element  is  of  course 
important,  mercury  is  even  more  effective  in  stimulating  the  body 
to  make  its  own  -fight.  For  that  reason  it  occupies  a  unique  and 
indispensable  place  in  the  management  of  the  disease. 

Mercury  is  given  in  syphilis  in  a  variety  of  ways.  In  all  cases 
it  is  the  metal  itself,  or  its  salts  that  is  used.  Mercury  taken  by 
mouth  as  pills  or  solutions  of  its  salts  attained  intense  popularity 
among  the  French  school  of  syphilologists,  but  has  now  been  shown 
to  be  good  enough  for  glossing  over  external  signs,  but  of  little  real 
effect  in  bringing  about  a  cure.  Especially  in  the  early  stages  of 
thie  disease,  Avhen  we  stake  everything  upon  the  hope  of  early  and 
complete  results,  mercury  by  mouth  is  an  anachronism  and  a  snare. 


■  .  87 

It  has  had  a  most  unfortunate  popularity  among  the  past  genera- 
tion of  physicians,  and  many  a  man  who  develops  serious  signs  of 
late  syphilis  in  later  life  owes  his  plight  to  his  doctor's  prescrip- 
tion of  mercurial  pills  in  the  days  of  his  chancre.  Pills  have  their 
place,  undoubtedly,  but  their  field  of  effective  action  is  very  limited. 
Mercury  is  also  given  by  injection  of  various  salts  under  the  skin 
or  into  the  muscles  at  various  intervals,  from  which  tissues  the  drug 
is  absorbed  into  the  blood.  This  form  of  treatment,  often  spoken  ot 
as  German,  has  many  advantages,  and  in  the  hands  of  the  expert 
has  a  high  degree  of  efficiency.  Mercury  is  also  given  by  incorporat- 
ing the  metal  with  a  grease  or  salve  and  rubbing  it  into  the  skin 
from  which  it  is  absorbed  in  part  directly  and  in  part  through  the 
lungs  from  evaporation  and  inhalation.  This  method  known  as  the 
inunction,  is  in  the  opinion  of  many  syphilographers  the  method 
par  excellence  for  administering  mercury  in  the  treatment  of  syph- 
ilis. It  has  the  disadvantage  of  seeming  dirty  and  smudgy  and  thus 
offensive  to  particular  patients.  But  for  the  certainty  of  its  action, 
and  its  ability  to  combine  high  doses  with  minimum  ill  effects,  it 
stands  unrivalled,  and  only  fails  to  attain  its  highest  usefulness 
through  objections  based  on  trivial  annoyances  rather  than  on  the 
actual  best  interests  of  the  patient. 

Mercury  Does  Not  Control  Contagiousness.— The  technic  of  the 
treatment  of  syphilis  with  mercury,  the  times  and  ways  and  reasons 
for  its  employment  cannot  be  discussed  here.  Its  intelligent  use  is 
perhaps  even  more  than  in  the  case  of  quinine  in  malaria,  an  art  in 
which  a  true  expertness  may  be  developed.  The  last  five  years  of  the 
practice  of  syphilology  have  only  served  to  raise  mercury  in  the  es- 
timation of  discriminating  observers.  Monumental  though  the  prog- 
ress made  possible  by  Ehrlich's  discovery  of  salvarsan  ("606")  has 
been,  the  new  drug  has  not  displaced  its  older  brother  as  an  essen- 
tial in  the  cure  of  syphilis.  The  one  great  defect  of  mercury  from 
the  standpoint  of  the  public  health  is  its  inability  to  control  conta- 
giousness. A  patient  receiving  it  by  the  most  vigorous  methods 
known  may  none  the  less  in  the  early,  contagious  stages  of  the  dis- 
ease develop  recurrent  sores  in  the  mouth  and  elsewhere,  which 
make  him  a  danger  to  others.  It  is  precisely  this  lack  in  the  older 
methods  of  treating  syphilis,  which  ''006"  supplies,  and  it  is  this 
combination  of  qualities  obtained  by  the  use  of  both  drugs  which 
justifies  the  statement  that  no  man  today  treats  syphilis  effectively 
who  does  not  use  both  "606"  and  mercury. 

The  Discovery  of  Arsphenamine — Ehrlich's  "606." — The  story  of 
the  discovery  of  arsphenamine  (salvarsan)  as  it  is  now  called  in 
the  United  States,  is  a  chapter  in  the  romance  of  scientific  discov- 
ery of  which  only  a  glimpse  is  possible  here.     Arsphenamine  is  the 


88 

American  technical  name  for  the  substance  known  as  Ehrlich's 
"606"  which  was  later  patented  in  Europe  and  the  United  States 
under  the  name  of  salvarsan.  Arsphenamine  is  a  compound  of 
arsenic  with  substances  derived  from  benzol,  the  chemical  agent 
which  forms  the  basis  of  modern  organic  chemistry.  It  is  to  all 
intents  and  purposes  a  dye.  Certain  dyes  are  poisonous.  The  ac- 
tion of  arsphenamine  upon  the  germs  of  syphilis  is  based  upon 
Ehrlich's  realization  that  if  a  poisonous  dye  or  stain  could  be  found 
which  would  pick  out  and  attach  itself  to  the  spirochaete  of  syphilis 
and  poison  it  without  doing  the  same  thing  for  the  cells  of  the 
human  body,  a  means  might  be  found  to  kill  the  germ  directly  in 
the  tissues  and  the  blood.  This  selective  affinity  of  dyes  for  certain 
tissues  or  for  certain  germs  is,  of  course,  familiar  in  medicine,  but 
Ehrlich's  application  of  it  to  the  problem  of  syphilis  was  unique  and 
was  said  to  have  been  inspired  by  the  effect  of  trypan  red,  a  special 
dye,  upon  germs  related  in  some  respects  to  those  of  syphilis.  After 
prolonged  experimentation,  Ehrlich  and  his  Japanese  collaborator, 
Hata,  with  the  cooperation  of  the  chemist  Bertheim,  succeeded  after 
606  attempts  (hence  the  name  '^606")  in  producing  the  substance 
dimethyl-diamino-arsenobenzol-dihydrochloride,  which  was  found  by 
'animal  experiment  to  be  able  to  pick  out  and  kill  the  spirochaete  of 
syphilis  in  the  blood  and  tissues  without  appreciably  injuring  the 
infected  animal.  It  is  not  too  much  to  say,  incidentally,  that  had 
the  germ  of  the  disease  not  been  discovered  by  Sehaudinn  and  Hoff- 
mann, and  the  transmissibility  of  the  disease  to  animals  demon- 
strated by  Metchinkoff  and  Roux,  the  work  of  Ehrlich  would  prob- 
ably have  been  neither  inspired  nor  carried  out.  Nothing  better 
illustrates  the  cosmopolitan  status  of  scientific  progress  or  the  in- 
terdependence of  scientific  men  upon  one  another,  regardless  of  race 
or  nationality,  than  the  modern  advances  in  the  knowledge  of  syph- 
ilis. Nor  is  it  possible  to  conceive  a  better  justification  of  experi- 
mental work  on  animals  than  that  afforded  by  the  results  of  the  com- 
bined efforts  of  these  scientists. 

The  Commercial  Status  of  Arsjjhenam  inc. ^ After  a  long  series  of 
careful  experiments  to  determine  its  efficiency  and  freedom  from 
danger,  Ehrlich  finally  announced  the  discovery  of  "606"  to  the 
world  in  December,  1910,  and  turned  the  formula  over  to  a  German 
firm  for  the  manufacture  and  marketing  of  the  drug  on  a  commer- 
cial scale.  In  accordance  with  the  accepted  custom  in  Germany, 
the  drug  and  every  detail  of  its  manufacture  were  carefully  pro- 
tected by  patents  in  all  countries.  The  tragic  but  little  appreciated 
result  was  that  long  after  the  legitimate  claims  of  the  inventor  had 
been  satisfied,  and  in  this  particular  Ehrlich  was  most  unselfish, 
this  drug,  so  precious  a  necessitj^  to  the  world,  remained  a  private 


89 

monopoly,  exploited  at  a  price  that  placed  it  out  of  the  reach  of  the 
poor  except  as  charity  made  provision  for  it,  and  restricted  in  its 
usefulness  by  merely  dollar  considerations.  It  required  the  com- 
manding necessities  of  the  war  to  bring  these  facts  to  light,  and  to 
open  the  way  for  competition  to  increase  its  accessibility.  In  prac- 
tically all  important  countries,  the  drug  is  now  being  manufac- 
tured under  government  license  and  a  variety  of  names.  In  the 
United  States  the  short-sighted  stringency  of  the  patents  for  a  time 
prevented  the  open  manufacture  of  the  drug  after  the  English  block- 
ade cut  off  German  exports.  The  monopoly  and  high  prices  con- 
tinued and  there  was  a  prolonged  period  when  the  medical  pro- 
fession and  the  sick  of  this  country  were  virtually  deprived  of  what 
should  under  a  more  enlightened  public  policy  have  been  cheap 
and  abundant.  The  drug  was  even  for  a  time  imported  from  Ger- 
many by  submarine  in  the  effort  to  maintain  control  of  the  patents. 
Finally,  after  the  declaration  of  war  with  Germany,  action  became 
imperative.  The  Adamson  Act  was  then  passed,  providing  inci- 
dentally for  the  manufacture  of  arsphenamine  by  American  firms 
of  demonstrated  competence,  under  federal  license.  This  has 
placed  the  United  States  for  the  time  being  on  the  same  basis  as 
European  nations.  The  tremendous  profits  reaped  by  the  German 
monopoly  are  apparent  from  the  fact  that  the  price  promptly  fell 
from  $4.50  to  |1.25  per  dose.  The  restoration  of  ante-bellum  prices 
for  raw  materials  could  greatly  reduce  even  this  figure.  It  must 
not  be  forgotten  that  the  present  satisfactory  situation  is  for  the 
duration  of  the  war  only,  and  that  public  opinion  back  of  a  funda- 
mental revision  of  our  patent  laws  is  necessary  to  make  the  change 
permanent.  It  is  not  too  soon  to  begin  to  impress  upon  American 
legislators  in  unmistakable  fashion,  that  ideas  and  substances  ca- 
pable of  altering  the  history  of  the  race  through  their  influence  on 
public  health  and  welfare,  cannot  remain  private  monopolies  and 
reap  exorbitant  profits  for  owners  and  exploiters  after  the  reason- 
able claims  of  the  inventor  are  satisfied. 

The  Fallacy  of  the  One-Dose  Cure. — Arsphenamine  was  intro- 
duced into  medicine  with  an  initial  fallacy  due  to  its  extreme  effec- 
tiveness in  animals,  and  the  spectacular  character  of  its  action  on 
syphilis  in  man.  Ehrlich  hoped  that  it  would  accomplish  a  cure 
of  the  disease  in  a  single  dose.  This  idea,  now  fully  understood  to 
be  erroneous,  gained  an  unfortunate  publicity  which  will  in  the 
course  of  the  next  decade  result  in  a  good  deal  of  late  syphilis  in 
patients  whose  early  signs  were  cleared  up  but  whose  disease  was 
not  cured,  by  the  single  injection  which  they  received. 

The  Action  of  Arsphenamine. — Arsphenamine  is  given  in  a  variety 
of  ways,  the  most  widely  used  being  direct  injection  of  a  solution  of 


it  into  the  blood  through  a  vein.  It  combines  in  some  way  with 
the  tissues  of  the  body  and  the  elements  of  the  blood,  and  the  com- 
bination, apparently,  is  deadly  for  the  germs,  but  almost  harmless, 
in  the  doses  used,  for  the  human  body.  The  effect  is  quite  miracu- 
lous. Within  twenty-four  hours  after  a  single  injection,  not  a 
spirochete  can  be  obtained  from  any  lesion  on  the  body,  although 
mucous  patches  and  condylomas  may  have  swarmed  with  them  be- 
fore the  treatment.  In  the  same  way  arsphenamine  is  able  to  wipe 
a  syphilitic  eruption  from  the  skin  almost  as  a  wet  sponge  cleans  the 
schoolboy's  slate.  Its  effect  therefore  is  to  control  contagiousness 
with  incomparable  efficiency,  and  to  produce  spectacular  and  rapid 
symptomatic  results.  It  requires  repeated  injections  to  make  the 
effects  lasting,  however,  and  mercury  must  be  invoked  for  final  cure. 
The  value  of  arsphenamine  has  one  qualification  from  the  patient's 
standpoint.  Too  little  of  it  may  be  worse  than  none  at  all,  and  may 
bring  on  gummatous  changes  before  the  secondary  period  is  well 
over,  this  through  certain  peculiarities  in  the  immunological  mech- 
anism of  syphilis.  If  the  administration  of  mercury  requires  a  re- 
fined therapeutic  judgment,  the  management  of  arsphenamine  treat- 
ment of  a  patient  requires  even  more,  and  too  much  or  too  little 
may  lead  to  unforeseen  consequences.  The  administration  of  the 
drug  at  competent  hands  is  not  dangerous,  but  must  be  surrounded 
with  precautions  established  by  experience.  Modifications  of  the 
original  Ehrlich  ^'606,"  particularly  "914"  or  neoarsphenamine,  are 
used,  but  the  detail  of  their  employment  has  no  place  in  this  dis- 
cussion. 


91  . 

CHAPTER  VII. 
THE  CURE  OF  SYPHIUS. 

What  is  Adequate  Treatment? — The  adequate  treatment  of  syph- 
ilis, by  whatever  means  it  may  be  approached,  is  not  a  matter  of 
days  or  weeks,  but  of  months  and  years.  In  this  simple  statement 
lies  four-fifths  of  the  problem  of  the  disease  in  personal  and  social 
life.  The  hold  of  the  Spirocheta  pallida  upon  the  human  body, 
once  it  is  established,  in  the  overwhelming  majority  of  cases  can- 
not be  broken  except  by  wearing  it  out,  so  to  speak.  Nothing  is 
easier  to  control  than  syphilis  so  far  as  many  of  the  symptoms  are 
concerned.  A  few  pills  even,  may  make  a  new  man  of  many  a 
wreck.  But  nothing  is  more  inexorable  or  more  unexpected  in  its 
"come-back."  Inadequate  treatment  carries  more  than  the  danger 
of  a  failure  to  cure.  It  makes  possible  under  an  outward  aspect 
of  calm,  the  recurrence  of  infectious  lesions,  the  transmission  of 
the  disease  to  others,  and  the  progress  of  the  disease  in  the  internal 
structures,  under  a  skin  kept  clean  and  whole  by  halfway  measures. 
Just  what  constitutes  adequate  treatment  can  only  be  determined  in 
the  individual  case.  It  may  be  safely  said  that  the  three  or  four 
injections  of  arsphenamine  and  a  few  mercurial  injections  or  rubs 
which  manj^  patients  get,  is  not  adequate.  One  or  two  negative 
Wassermann  tests  are  no  measure  of  adequacy,  popular  though  this 
fallacy  is.  Our  last  resort  must  often  be  the  old  rules  of  thumb 
which  still  retain  a  place  in  the  management  of  the  disease  that 
cannot  be  shaken  by  any  of  the  epochal  discoveries  of  the  last  twenty 
years.  In  fact  some  of  the  most  recent  work  on  syphilis  is  tending 
to  show  that  what  even  a  good  deal  of  treatment  accomplishes  is 
simply  a  reduction  of  the  infection  to  harmlessuess,  rather  than  a 
cure  signalized  bj^  the  killing  off  of  all  germs. 

An  Interpretation  of  the  Cure  of  Syphilis. — In  the  face  of  such 
considerations,  it  is  becoming  increasing!}^  difficult  to  tell  the  pa- 
tient just  what  cure  means  and  Avhat  will  secure  it.  It  should  in 
general  be  understood  that  for  all  practical  purposes,  cure  means 
lifelong  freedom,  from  all  symptoms  and  signs  of  the  disease,  and 
no  risk  of  transmission  to  others,  hereditarily  or  directly.  Even 
abortive  cure,  to  which  we  pin  our  hopes,  still  contains  a  liberal  ad- 
inixture  of  faith,  which  only  the  clarifying  influence  of  time  can  jus- 
tify or  discredit.  To  tell  a  man  with  a  four-day-old  primary  lesion 
that  six  months  of  treatment  will  cure  him  is  near-folly — to  tell  him 
that  a  year  will  do  it  is  rash,  to  tell  him  that  two  years  will  see 
him  well,  is  to  enter  the  borders  of  conservatism.  In  the  fully  d^ 
veloped  secondary  case,  not  only  are  two  and  perliaps  tliree  years 
of  systematic  treatment  necessary,  but  there  must  be  a  succeeding 


92 

m 

period  of  probation  before  cure  is  confirmed  in  which  the  patient 
must  show  no  signs  of  the  disease,  not  only  to  the  Wassermann  test, 
but  to  a  variety  of  other  examinations  intended  to  reach  all  the 
structures  that  syphilis  is  known  to  affect.  This  advances  the  aver- 
age period  of  time  before  the  pronouncing  of  a  cure  in  a  fully  de- 
veloped case  in  the  secondary  stage,  to  five  years  from  the  time 
treatment  was  begun.  All  that  can  be  said  of  a  cure  thus  carried 
out,  is  that  its  value  while  not  absolute,  is  born  out  by  the  over- 
whelming mass  of  human  experience  with  the  disease.  The  risk  of 
persistence  of  a  syphilis  after  these  demands  have  been  satisfied  is 
comparable  to  the  risk  of  death  that  is  inseparable  from  the  mere 
fact  of  living.  So  far  as  our  human  fallibility  allows,  we  say  that 
the  average  man  who  has  had  a  fully  developed  secondary  syphilis 
treated  by  the  most  modern  methods  for  three  years,  and  has  been 
free  from  every  symptom  and  sign  for  two  years  after  all  treatment 
is  stopped,  has  returned  to  the  class  of  insurable  risks.  He  is  less 
likely  to  have  a  relapse  than  he  is  to  fall  from  the  top  of  a  building 
or  be  hit  by  an  automobile  rounding  a  corner. 

The  Time  Factor  in  Cure. — Time  is,  a  vital  factor  in  the  treatment 
of  syphilis,  and  the  time  at  which  treatment  is  begun  is  no  less  so 
than  the  time  for  which  it  is  continued.  Abortive  cure  depends  on 
time  and  the  recognition'  of  the  germ.  Similarly  the  outlook  on 
late  syphilis  once  past  the  secondary  stage  depends  on  the  age  of  the 
infection  and  the  damage  already  done.  In  late  syphilis  of  the 
nervous  system  and  of  important  organs,  we  do  not  speak  of  cure, 
rather  of  arrest  and  the  reinforcement  of  the  patient's  resistance 
from  time  to  time  by  treatment,  until  he  shall  have  lived  out  his 
days.  Just  at  what  moment  in  the  life  history  of  an  infection  the 
bright  outlook  of  primary  and  secondary  syphilis  passes  over  into 
the  less  hopeful  prospect  of  late  syphilis  can  be  decided  only  in  the 
individual  case  apd  by  the  conservative  instinct  of  the  syphilog- 
rapher.  Personally,  the  author  believes  the  disease  to  be  curable 
in  its  earlier  stages,  but  does  not  encourage  any  patient  to  cast  all 
caution  to  the  winds  and  rely  implicitly  on  a  dramatic  word  of  final 
release — "you  are  cured."  Occasional  expert  observation  through 
life  for  the  person  who  has  had  syphilis  has  the  same  value  that  it 
has  in  tuberculosis,  as  an  insurance  against  the  fallibility  of  human 
judgment. 

Determination  of  the  Fact  of  Cure. — The  answering  of  the  ques- 
tion "Am  I  cured  of  syphilis,"  like  the  settlement  of  the  question  of 
the  cure  of  gonorrhea,  is  often  a  matter  for  experts.  The  first  es- 
sential of  proof  is  a  series  of  negative  blood  tests  covering  a  period 
of  from  one  to  two  years.  Many  syphilographers  believe  that  a 
special  series  of  tests  called  a  ''provocative"  should  be  carried  out. 


93 

This  consists  in  taking  blood  tests  at  various  intervals  within  a 
month  after  an  injection  of  arsphenamine  ("606").  It  is  increas- 
ingly the  belief  of  men  who  see  a  great  deal  of  late  syphilis  that  no 
case  should  be  discharged  from  medical  care  without  an  examina- 
tion of  the  spinal  fluid  by  an  expert,  since  syphilis  of  the  nervous 
system  may  remain  concealed  for  years  before  the  outbreak,  and 
only  be  recognized  during  the  latent  period  by  the  testing  of  the 
spinal  fluid.  An  examination  to  prove  the  cure  of  syphilis  should 
also  extend  into  every  nook  and  corner  of  the  body,  with  tests  of  the 
eyes,  the  ears,  and  other  important  structures  by  specialists  com- 
petent to  pass  an  opinion  upon  them.  Only  by  this  apparently 
needless  precaution  is  it  possible  to  reduce  the  chance  of  a  mistaken 
or  premature  decision. 

Treatment  of  Hereditary  Syphilis. — The  treatment  of  hereditary 
syphilis  is  in  many  respects  a  much  more  hopeful  matter  than  a 
consideration  of  the  nature  of  the  disease  suggests.  Children  who 
survive  it  are  aided  by  a  resistance  that  is  an  invaluable  asset.  If 
systematic  intense  measures  could  be  applied  to  every  mother  who 
has  syphilis,  while  she  is  carrying  the  child,  we  would  witness  an 
immediate  and  surprising  decrease  in  the  transmission  of  the  in- 
fection to  offspring.  So  effective  is  this  treatment  of  the  mother  be- 
fore the  birth  of  the  child  that  it  is  the  bounden  duty  of  every  phy- 
sician called  upon  to  deal  with  pregnant  women  to  be  familiar  with 
the  essentials  of  syphilology  and  to  secure  for  those  under  his  care 
proper  expert  investigation  and  treatrnjent  if  the  findings  show  the 
presence  of  the  disease.  If  the  new-born  child  has  syphilis,  its  pres- 
ervation depends  upon  constant  unremitting  care  combined  with 
skilled  treatment.  The  baby  must  be  nursed  by  the  mother.  In 
older  children  the  treatment  of  the  complications  of  hereditary 
syphilis  becomes  a  problem  for  the  state.  The  successful  treatment 
of  interstitial  keratitis,  for  example,  may  call  for  months  in  the 
hospital  and  may  delay  the  child's  education  enough  to  damage  per- 
manently its  social  efficiency  and  waste  its  mental  powers.  The 
Scandinavian  countries,  through  the  influence  of  the  great  syphilog- 
rapher  Weylander,  treat  these  children  in  special  school-hospitals, 
or  homes,  with  really  wonderful  results.  Few  experiences  are  more 
gratifying  to  the  expert  than  to  transform  the  little  shrunken  body 
with  its  bowed  head  and  aching,  red,  and  all  but  sightless  eyes,  into 
robust  and  laughing  youth.  The  State  of  Michigan  is  conspicuous 
in  this  country  in  its  provision  for  the  care  of  children  who  can 
be  benefited  by  medical  treatment,  those  with  hereditary  syphilis 
among  the  number. 


94 

CHAPTER  VIII. 
PUBLIC  AND  PERSONAL  HYGIENE  OF  SYPHILIS. 

Summary  of  Facts  Regarding  Contagiousness. t^SVq  have  now 
reached  the  point  where  it  is  possible  to  summarize  the  problem  of 
syphilis  as  it  concerns  personal  and  public  health.  Syphilis  is  a 
contagious  infection.  For  practical  purposes,  it  is  a  danger  to 
others  only  during  the  primary  stage,  the  secondary  stage,  and  such 
part  of  the  latent  period  as  may  be  marked  by  the  recurrence  of 
contagious  lesions  about  the  mouth  and  genitals.  Any  syphilitic 
lesion  in  the  stages  named  is  dangerous  if  it  is  moist.  The  sores 
of  late  syphilis,  occurring  as  they  do  after  the  larger  part  of  the 
germs  have  died  off  in  the  body,  are  not  dangerous.  In  fact,  it  may 
be  said  of  syphilis  in  general  that  danger  is  inversely  proportional 
to  glare  and  conspicuousness.  There  move  among  us  every  day  per- 
sons with  dangerous  syphilitic  lesions,  for  whom  we  would  never 
think  to  turn  aside,  though  we  would  shun  one  who  had  a  harmless 
"running  sore"  as  if  he  were  a  leper.  Categorically,  the  important 
principles  governing  the  transmission  of  syphilis  may  be  sum- 
marized as  follows : 

The  disease  is  transmitted  only  by  the  transfer  of  the  germs. 
Personal,  immediate  contact  with  an  infectious  sore  or  lesion  stands 
first  and  foremost  in  the  spread  of  the  disease.  The  germs  of  syph- 
ilis cannot  live  long  away  from  the  body,  or  in  the  presence  of  air. 
They  are  killed  at  once  by  drying.  They  are  not  distributed  about 
by  objects  that  have  only  remote  contact  with  syphilitics,  such  as 
furniture,  door  knobs,  bath  tubs,  and  even  toilet  seats.  The  dan- 
gerous articles  are  instruments  recently  used,  articles  that  are  put 
in  the  mouth,  such  as  silverware,  cups,  pipes,  etc.,  clothing  or 
dressings  moist  with  discharges.  Germs  of  syphilis  deposited  on 
foreign  objects,  die  at  once  on  contact  with  so  weak  an  antiseptic 
as  soap  and  water.  The  washing  of  all  personal  articles  in  hot  soap 
suds  effectually  sterilizes  them  so  far  as  this  disease  is  concerned. 

Non-genital  Syphilis. — Syphilis  is  non-genital — that  is,  the  pri- 
mary sore  occurs  elsewhere  than  on  the  genitalia  in  from  5  to  10 
per  cent  of  all  cases.  These  are  older  figures,  and  a  greater  ex- 
pertness  in  recognizing  the  early  onset  of  the  disease  will  increase 
the  amount  of  non-genital  syphilis  recognized.  Physicians  aad 
nurses,  and  also  members  of  families  in  which  there  is  a  careless 
syphilitic,  or  in  which  there  is  crowding  and  bad  hygiene  are  con- 
spicuous victims  of  this  mode  of  acquiring  the  disease.  It  is  said 
that  in  parts  of  Russia,  genital  infection  is  the  exception,  and  non- 
genital  the  rule,  and  the  same  observation  was  made  by  Tnllidge  in 
connection  with  Austrian  troops  in  the  war.     The  chancre  may  ap- 


95 

^^ear  on  the  lip,  the  tongue,  the  tonsil,  the  eye,  the  finger,  the  nipple 
or  any  other  part  of  the  body,  even  to  the  septum  of  the  nose  .and 
the  palm  of  the  hand. 

The  Engagement  Chancre. — An  important  phase  of  extragenital 
syphilis  is  the  syphilis  of  intimate  non-genital  contacts — kissing  and 
caresses.  Into  this  group  fall  the  engagement  chancre  on  the  lips 
of  the  young  girl  whose  fiance  acquired  his  infection  by  resorting  to 
some  other  woman  for  the  relief  of  the  excitement  of  his  courtship ; 
the  chancres  on  the  eyelids,  the  lips  and  the  cheeks  of  children  from 
the  kisses  of  infected  parents  or  brothers  and  sisters,  or  from  stran- 
gers ;  the  chancres  of  the  finger  that  are  acquired  in  other  than  inno- 
cent ways. 

Genital  Transmission  of  Syphilis. — The  genital  transmission  of 
syphilis  covers  from  80  ^to  90  per  cent  of  all  cases,  according  again 
to  older  figures.  About  50  per  cent  of  the  infections  of  married 
women  have  seemed  to  me  to  be  contracted  in  marriage,  though 
Fournier  gave  20  per  cent  as  his  estimate.  The  physiological 
reasons  for  the  importance  of  genital  transmission  have  been  dis- 
cussed. No  person  who  dispassionately  reviews  the  facts  can  long 
cherish  the  belief  that  guilt  or  innocence  has  any  part  in  the  de- 
velopments of  the  peculiar  habits  of  the  Spirochaeta  pallida,  or 
maintain  that  the  innocent  and  loyal  wife  or  husband  or  the  un- 
knowing, unoffending  child  should  be  besmirched  by  our  prurience 
simply  because  the  organisui  is  an  anerobe  of  low  vitality,  requiring 
special  conditions  for  its  growth. 

Duration  of  Contagiousness.  Effect  of  Toljacco,  Dirt,  Etc. — The 
average  syphilitic  infection,  untreated,  must  be  rated  as  contagious 
for  a  period  of  at  least  five  years  from  its  onset.  Lapse  of  time 
with  progress  toward  the  non-contagious  tertiary  or  late  stage,  soon- 
er or  later  disposes  of  the  public  menace  of  every  syphilitic.  This 
is  scant  consolation,  however,  when  it  is  recalled  that  the  contagious 
periods  of  the  diseases  of  children  for  example,  seldom  occupy  the 
number  of  days  or  weeks  that  syphilis  does  years.  The  contagious- 
ness of  syphilis  is  increased  by  anything  which  tends,  as  do  tobacco, 
dirt  and  irritation,  to  produce  moist  recurrences  about  the  mouth 
and  genitals.  The  contagiousness  of  syphilis  is  diminished,  and  the 
danger  period  shortened,  by  modern  treatment. 

Arsphenanvine  in  the  Control  of  Contagiousness  in  Syphilis. — 
Any  device  or  remedy  which  shortens  the  contagious  period  of  an 
infection,  has  life-saving  value.  In  this  class  we  must  place  arsphe- 
namine,  whose  ability  quickly  to  destroy  the  germs  of  syphilis  in 
contagious  sores  is  one  of  the  most  brilliant  contributions  to  the 
modern  campaign  against  the  disease.  Quarantine  for  syphilis,  as 
it  is  practiced  in  other  contagious  diseases,  is  impracticable,  and 


9Q 

fortunately  it  has  at  last  become  unnecessary.  A  twenty-four  hour 
stay  in  a  hospital  with  a  single  injection  of  "606"  does  away  for  the 
time  being  with  the  need  of  it.  It  should  never  be  forgotten,  how- 
ever, that  it  is  a  short-sighted  policy  which  provides  only  enough 
arsphenamine  to  temporarily  destroy  the  germs.  Such  a  policy  in- 
flicts deliberate  injury  upon  the  patient  by  exposing  him  to  the 
risk  of  dangerous  complications,  and  does  not  protect  the  public 
from  his  relapses  any  more  effectively  than  the  old-time  use  of  mer- 
cury. Every  case  must  be  adequately  treated  from  the  broad  stand- 
point, as  syphilis,  not  from  the  narrow  point  of  view  of  merely  re- 
ducing contagiousness  for  the  time  being.  By  adopting  the  former 
standard,  and  backing  it  with  our  dollars  and  our  laws,  we  will 
best  serve  both  the  interests  of  the  public  and  those  of  the  patient 
himself.  Good  all-around  treatment  with  salvarsan  and  mercury, 
while  it  can  never  unconditionally  guarantee  the  non-infectiousness 
of  a  syphilitic,  least  of  all  in  the  intimacies  of  life,  can  none  the 
less  reduce  the  risk  in  ordinary  relations  practically  to  the  vanish- 
ing point. 

Personal  Responsibility  in  the  Transmission  of  Syphilis. — There 
enters  into  the  control  of  syphilis  as  a  contagious  disease,  the  same 
problem  of  personal  responsibility  which  appears  in  gonorrhea. 
In  those  who  are  ignorant,  the  transmission  of  syphilis  to  others 
goes  on  unawares ;  in  those  who  are  indifferent,  the  risk  of  infecting 
others  is  ignored — sometimes  even  deliberately  recognized  and  em- 
ployed as  a  means  of  vengeance.  The  extent  of  irresponsibility  in 
the  transmission  of  the  disease  is  large,  and  it  bears  no  direct  rela- 
tion to  the  supposed  intelligence  of  the  person  who  transmits  the 
disease.  I  have  known  Croatian  laborers  who  barely  understood 
the  words  in  which  they  were  addressed,  to  take  precautions  to 
protect  others  which  conformed  to  an  ideal  code  of  unselfish  consid- 
eration. On  the  other  hand,  I  have  had  trained  nurses,  infected  in 
illicit  sexual  relations,  leave  my  consulting  room  after  the  most 
explicit  instruction  as  to  the  danger  for  others,  and  marry  healthy 
partners  before  they  were  non-infectiou(S.  The  transmission  of 
syphilis  is  too  often  dependent  on  a  character  factor  which  no 
amount  of  treatment  can  reach.  The  rapidly  developing  modern 
public  health  program  for  the  control  of  genital  infections  is  for- 
tunately taking  account  of  this  phase  of  the  problem,  and  is  placing 
the  irresponsible  syphilitic  within  the  grasp  of  the  law.  Syphilis 
gives  even  the  conscientious  patient  all  too  few  reminders  of  his 
duty.  A  little  treatment,  and  everything  including  the  patient,  van- 
ishes. I  remember  in  my  own  dispensary  days  the  signal  that 
marked  the  intention  of  many  a  patient  to  pronounce  himself  cured 
and  disappear.     A  basket  of  tomatoes,  or  some  fruit,  or  a  box  of 


97 

cigars  would  appear  on  the  window  sill  and  then  there  would  be 
a  vacancy  in  the  treatment  line,  perhaps  all  that  was  left  to  sym- 
bolize the  value  of  hours  of  as  ardent  persuasion  on  my  part  and 
as  complete  a  good  will  as  ever  glorified  an  evangelist  pleading  for 
a  lost  soul.  Now  with  the  plenary  powers  of  the  police  and  the 
searching  eye  of  the  social  worker  to  aid,  the  old-time  shrug  and 
"What's  the  use"  that  was  our  only  resort  in  our  struggle  with 
irresponsibility,  has  lost  its  sardonic  meaning.  A  great  deal  of 
syphilis  can  be  held  to  treatment  and  to  a  hygiene  which  protects 
others,  through  the^  personal  effort  of  the  physician.  That  part  of 
it  which  declines  the  voluntary  assumption  of  its  responsibility 
must  be  forced,  and  forced  it  will  be. 


98 

u  CHAPTER  IX. 

SYPHILIS  AND  MARRIAGE. 

The  fitness  for  marriage  of  a  person  who  has  had  syphilis  must 
be  judged  by  two  criteria.  It  is  a  matter  of  some  importance  that 
the  non-infectious  marital  partner  be  able  to  measure  up  to  the 
social  responsibilities  of  marriage.  Williams^  showed  for  example, 
in  an  investigation  of  100  men  dying  in  Massachusetts  of  syphilitic 
insanity  that  78  women  and  109  children  were  thrown  upon  society 
without  the  protection  of  a  wage-earner,  the  state  paid  |39,312  for 
the  care  of  the  men  alone,  and  ten  of  them  represented  a  financial 
loss  of  1212,248.  It  is  therefore  usually  inadvisable  for  patients 
exhibiting  serious  late  complications  which  are  likely  to  incapacitate 
them,  to  marry,  even  though  there  is  no  risk  of  transmitting  the 
disease,  unless  the  partner  knowingly  assumes  the  risk  of  having  au 
invalid  on  his  hands.  Patients  in  the  infectious  stage  of  the  dis- 
ease should  be  governed  by  the  so-called  Hoffman  or  five-year  rule, 
which  is  practically  identical  with  the  standard  for  cure  in  the 
fully  developed  case  of  secondary  syphilis.  There  is  a  tendency  on 
the  part  of  a  few  observers  to  let  down  the  bars  on  the  strength  of 
the  effectiveness  of  modern  treatment.  In  the  opinion  of  conserva- 
tive syphilologists,  however,  this  relaxation  is  premature.  It  is 
safe  to  say  that  there  is  no  longer  any  justification  for  the  prolonged 
restrictions  covering  most  of  a  life  time,  advocated  by  men  of  the 
past  generation,  like  Fournier,  whose  experience  was  affected  by  the 
relative  inefficiency  of  the  methods  of  treatment  then  employed.  It 
must  be  emphatically  stated  that  the  same  rule  should  apply  to  the 
engagement  to  marry  that  applies  to  marriage  itself.  The  Ameri- 
can engagement  is  a  period  of  informality  andintimacy  which  may 
even  be  synonymous  with  the  most  intimate  contact.  No  person 
having  the  welfare  of  a  young  girl  in  charge  is  justified  in  permit- 
ting her  to  enter  upon  an  engagement,  or  intimacies  approaching  it, 
that  cannot  be  thought  of  as  terminating  in  marriage.  The  careful 
investigation  of  the  actual  or  potential  fiance  is  the  only  way  to 
avoid  the  all  too  frequent  lip  and  tonsillar  chancre  in  trusting  girls. 

Syphilis  and  the  Medical  'Examination  Before  Marriage. — From 
the  sj'philologic  standpoint  the  determination  of  the  fitness  of  a 
person  who  presents  himself  for  medical  examination  before  mar- 
riage offers  problems  not  unlike  those  which  beset  the  examination 
of  gonorrhea.  The  value  of  the  'certification  must  depend  to  no 
small  extent  upon  the  status  of  the  examiner  as  an  expert  on  syph- 
ilis. If  he  knows  so  little  about  the  disease  as  to  be  content  with 
a  single  negative  Wassermann  test,  which  by  the  way  is  the  favorite 

^  Williams,  F.  E. :   Relntion  of  alcohol  and  syphilis  to  mental  hygiene.     Am.  Jour 
Pub.   Health,  I'Jlf..  vi,  1272. 


99 

legislative  sop  to  public  sentiment  on  this  matter,  his  opinion  will 
be  worth  exactly  nothing.  A  thorough  physical  examination  is 
necessary,  an  honest  history  from  the  patient,  some  acquaintance 
with  his  family  tree  and  traditions,  and  repeated  confirmatory  tests 
upon  the  blood.  If  there  seems  ground  for  suspicion,  the  complete 
procedure  for  determining  the  fact  of  cure  may  be  undertaken  with 
its  "provocative"  blood  test,  examination  of  the  eye,  ear  and  nerv- 
ous system,  and  of  the  spinal  fluid.  It  is  obvious  that  this  is,  in 
the  vernacular  ''a  large  order,"  and  will  not  attain  to  popularity 
without  a  prolonged  and  vigorous  educational  campaign.  The  phy- 
sical fitness  of  candidates  for  marriage  should  be  the  occasion  for 
an  all-around  family  conference  on  both  sides,  with  seats  at  the 
conference  table  for  both  the  medical  expert  and  the  minister.  The 
laws  which  govern  professional  medical  confidence,  and  protect  the 
secrets  of  rascals  should  on  this  occasion  be  adjourned,  as  they  are 
now  in  the  progressive  state  of  Ohio  for  example."^ 

ResponsiUUty  of  the  Church. — The  church  has,  I  believe,  a  little 
appreciated  and  much  needed  power,  in  this  matter.  In  these  days 
it  takes  a  man  or  woman  of  more  than  ordinary  force  and  determi- 
nation to  brave  the  inertia  of  popular  silence,  distrust  and  mis- 
conception, and  insist  that  the  one  he  or  she  loves  and  trusts,  shall 
be  appraised  on  the  score  of  physical  fitness  for  the  relation  into 
which  they  shall  enter.  The  vigorous  and  determined  stand  of  the 
clergy  in  support  of  physical  examination  of  candidates  for  the 
religious  ceremony  will  go  far  to  bolster  the  timid  and  spread  the 
new  conception  of  responsibility.  The  author  had  the  experience  of 
seeing  the  photograph  of  a  partially  treated  patient  and  his  bride 
appear  in  the  pages  of  a  supposedly  progressive  newspaper.  On 
reading  the  paragraph  accompanying  it,  he  found  that  this  enterpris- 
ing journal  had  furnished  even  the  officiating  minister  who  made 
this  marriage  possible.  All  that  remained  for  him  to  do  was  to 
pray  that  the  arsphenamine  he  had  injected  so  long  as  the  patient 
chose  to  continue  treatment,  would  do  double  duty.  How  much  bet- 
ter would  it  have  been,  and  how  much  more  progressive,  if  the  min- 
ister who  unknowingly  contributed  to  this  consummation  had  swung 
his  influence  against  the  snap-shot  marriage  and  avoided  even  the 
semblance  of  acting  as  stool  pigeon  to  an  irresponsible.  The  church 
has  a  mission  here  which  it  cannot  long  neglect. 

ResponsiUUty  of  the  Medical  Profession.— The  medical  profession 
must  in  its  turn  bear  its  share  of  the  blame  for  marriages  consum- 
mated after  inadequate  tests.  ''But  the  doctor  told  me  I  was  well- 
he  said  my  blood  was  clean"  (Wassermann  negative)  is  an  nil  too 
familiar  cry  from  fathers  when  examination  of  mother  and  child 

J  Amendment  to   Section  1275,  Genera]   Cocle,  n.  177. 


100 

sliows  the  presence  of  the  disease.  Until,  for  one  thing  the  newer 
standards  for  the  detection  and  cure  of  syphilis  have  become  the 
common  property  of  the  medical  profession,  or  the  care  of  the  dis- 
e^e  is  concentrated  on  the  hands  of  experts,  it  will  be  futile  to  ex- 
pect striking  results  from  the  medical  examination  of  candidates 
for  marriage. 

,/  Eummanj  of  the  General  Outlook. — The  extinction  of  syphilis  is  a 
coxLsimimation  in  public  health  which  has  more  prospect  of  concrete 
foMilment  than  in  the  case  of  any  other  of  the  four  great  modern 
plagues.  Tuberculosis,  while  a  disease  of  known  cause,  lacks  the 
means  for  such  effective  treatment  and  control  of  contagion  as  are 
available  in  syphilis.  Cancer  is  still  shrouded  in  obscurity — of 
imknown  cause,  of  terrific  fatality,  definitely  remediable  only  in  its 
earliest  stages,  little  understood  as  to  its  prevention.  Gonorrhea, 
preventable,  but  with  its  long  period  of  uncontrolled  infectiousness 
and  train  of  complications  following  upon  a  neglect  which  the  dis- 
ease itself  encourages  in  every  possible  way,  lacks  also  the  striking, 
the  effective,  the  specific  cure.  Syphilis  alone  of  the  four  is  at  our 
mercy.  A  method  of  prevention  to  be  discussed  later,  whose  ef- 
ficiency is  very  high;  methods  of  treatment  which  bid  fair  to  cure 
aearlj^  every  case  taken  in  time ;  methods  of  recognition  in  the  form 
©f  blood  and  other  tests  which  have  some  of  the  smallest  margins  of 
error  in  medicine ;  control  of  contagiousness  which  is  more  absolute, 
immediate  and  effective  than  the  most  rigorous  quarantine,  all  point 
to  possibilities,  whose  realization  is  only  a  matter  of  time.  A  mat- 
ter of  time,  and  of  public  education — for  nothing  stands  out  more 
clearly  than  the  fact  that  our  refusal,  not  our  inability  to  control, 
explains  the  existing  situation.  Free,  abundant,  effective  early 
treatment  and  preventive  measures,  with  compulsion  where  neces- 
sary, will  from  the  medical  side,  enable  us  to  hold  the  situation  in 
the,  hollow  of  the  hand.  That  the  medical  solution  shall  be  touched 
with  idealism  and  inspired  by  great  principles,  must  be  our  next 
concern. 


PART  IV. 

THE  SOCIAL,  PSYCHOLOGIC,  AND  ECONOMIC 

BACKGROUND  OF  SYPHILIS  AND 

GONORRHEA. 


103 

CHAPTER  I. 
THE  PUBLIC  VIEWPOINT. 

Every  bodily  ailment  has  its  social  and  psychologic  background — 
a  fact  that  physicians  themselves  are  often  only  too  prone  to  forget, 
or  to  ignore  under  the  mistaken  belief  that  such  detachment  is  an 
essential  part  of  the  scientific  point  of  view.  No  presentation  of  the 
subject  of  syphilis  and  gonorrhea  can  lay  any  claim  to  breadth  or 
completeness  which  does  not  point  out  at  least  the  principal  factors 
in  human  nature  and  the  social  order  that  underlie  the  powerful 
hold  that  these  diseases  have  upon  the  race. 

The  Inertia  of  PuMic  Opinion. — The  medical  consultant  on  the 
genital  infections  must  have  the  spirit  of  a  pioneer  and  aim  to  mold 
public  opinion.  Too  often  he  is  thought  of  as  a  devil's  porter,  busy 
throwing  wide  the  gates.  About  him  there  seems  at  times  to  lie  a 
vast,  and  occasionally  a  vociferous  wilderness -of  ignorance,  preju- 
dice and  distrust.  More  to  be  feared  than  outspoken  aversion  and 
contempt,  is,  too,  a  certain  silent,  veiled,  but  peculiarly  intense  and 
irrational  hostility  which  sometimes  marks  the  thought  of  those  who 
are  otherwise  intelligent  and  cultivated  people,  on  the  question  of 
Avhat  to  do  with,  and  for,  the  syphilitic  and  the  man  or  woman  with 
gonorrhea.  The  physician  himself,  to  whom  no  sickness  should  be 
alien  or  deserving  of  less  than  his  best,  too  often  feels  that  syphilis 
and  gonorrhea  are  in  a  class  by  themselves  and  leaves  them  coldly 
to  the  exploitation  of  quackery  and  incompetence.  His  attitude  is 
simply  a  reflex  of  the  public  thought.  It  still  takes  a  measure  of 
hardihood,  even  in  this  comparatively  enlightened  day  to  permit 
one's  name  to  become  synonymous  in  a  locality  with  a  trafficker  in 
the  unmentionable,  the  dubious  shepherd  of  black  sheep.  Yet  after 
all  there  is  something  to  inspire  in  the  work.  Those  who  can  bring 
to  the  care  of  the  modern  venereal  leper  the  spirit  of  a  Father 
Damien  will  have  a  real  mission.  There  are  few  who  reap  more 
generously  the  rewards  of  gratitude  and  whole-hearted  fellowship 
than  those  who  are  able  to  appreciate  and  lighten  the  trials  of  that 
portion  of  the  sick  whom  public  misunderstanding  condemns  with- 
out a  hearing.  False  tradition  is  not  adamant.  For  those  who  at- 
tempt without  cynicism  and  with  adequate  special  knowledge  to 
illuminate  the  problem  of  sex  diseases  it  seems  as  if  there  must 
exist  an  actual  and  definite  public  need,  and  a  promise  of  public 
comprehension  and  response. 

The  state  of  public  opinion  on  syphilis  and  gonorrhea  can  best  be 
appreciated  by  an  effort  at  critical  analj^sis.  It  has  a  definite 
psychology.  The  inertia  that  seems  to  characterize  it  is  not  hope- 
less.    It  can  be  traced  to  a  half  dozen  or  so  of  more  or  less  conflict- 


104 

ing  and  inhibitive  points  of  view.  To  attack  and  demolish  or  to 
reconstruct  these  individual  misconceptions  is  to  convert  the  heathen 
and  uphold  the  larger  gospel  "Salus  populi  suprema  lex." 

An  Analysis  of  Current  Misconceptions. — My  ovi^n  experience  with 
the  psychological  problem  has  led  me  to  summarize  the  basis  of 
this  longstanding  public  indifference  and  antagonism  under  the 
following  heads: 

1.  Ignorance  of  the  facts  in  regard  to  the  tremendous  prevalence 
and  wide  distribution  of  syphilis  and  gonorrhea.  Very  few  people 
possess  the  special  knowledge  to  convince  them  that  these  diseases 
cannot  be  evidence  of  inherent  disreputability  and  viciousness,  or 
the  property  of  any  special  class. 

2.  Confusion  of  the  issue  with  the  problem  of  commercialized 
prostitution. 

3.  Exaggerated  notions  of  the  contagiousness  of  syphilis  and 
gonorrhea,  especially  the  former. 

4.  The  belief  that  the  horrors  of  syphilis  and  gonorrhea  have 
moral  value — that  they  act  as  deterrents  to  sexual  license. 

5.  Pharisaical  self-righteousness. 

6.  The  belief  that  syphilis  and  gonorrhea  are  well-deserved  pun- 
ishments visited  upon  offenders  against  moral  and  natural  laws. 

Public  Ignorance  of  the  Facts. — Public  ignorance  of  the  facts  is 
an  outstanding  and  basic  factor.  Even  highly  trained,  cultivated 
and  well-informed  people,  not  excluding  from  that  number  phy- 
sicians of  wide  experience,  still  cherish  the  lingering  belief  that 
syphilis  is  largely,  and  gonorrhea  almost  entirely,  a  proof  of  moral 
degradation  and  the  property  of  down  and  outs.  If  sexual  longings 
and  illicit  gratifications  were  limited  to  a  few,  and  if  absolute 
sexual  regularity  were  the  only  proof  of  sound  character,  the  bulk 
of  humanity  would  have  to  be  classed  as  vicious  and  degraded.  It 
is  not  cynicism  that  prompts  the  syphilographer  to  urge  the  drop- 
ping of  all  social  distinctions  in  the  survey  of  the  situation  in  his 
field.  It  is  a  far  more  sordid  cynicism  that  can  believe  so  ill  of 
human  nature  as  to  hold  that  because  60  per  cent  of  men  have  had 
gonorrhea,  60  per  cent  of  men  are  outside  the  pale  of  decency  and 
honor.  It  is  equall}^  impossible  to  believe  that  vileness  clings  to 
one  in  five  adults  with  syphilis  while  the  remaining  four  with  Was- 
sermann  negative  passports,  enter  the  gates  of  social  respectability. 
Distinctions  based  on  social  status  and  class  are  irrational  and  un- 
founded to  one  who  meets  the  situation  day  in  and  day  out.  For 
one  thing  they  have  a  reflex  effect  that  interferes  with  the  medical 
diagnosis  of  the  disease.  How  many  carefully  performed  and  ac- 
curate positive  Wassermann  tests  does  it  take  to  establish  the  pres- 
ence of  syphilis?     Far  from  being  a  purely  medical  question  as  tho 


105 

syphilologist  would  insist,  the  public  and  even  physicians,  too  often 
believe  it  is  a  social  one.  One  positive  test  will  usually  convict  a 
laborer  over  his  own  denial,  two  may  indict  a  railroad  president  or 
a  banker,  but  I  have  known  three  to  be  insufficient  to  satisfy  a 
clinician  of  the  "guilt"  of  a  minister.  To  one  who  knows  even  the 
preliminaries  of  his  subject,  such  situations  would  be  laughable 
were  it  not  for  the  tragic  blindness  they  imply.  This  illustration, 
harsh  though  it  is,  exemplifies  the  ever-present  fallacy  in  all  public 
thougjit  about  syphilis  and  gonorrhea — the  uncritical  injection  of 
moral  issues  and  class  distinctions  into  the  problem.  To  the  criti- 
cal judgment,  syphilis  and  gonorrhea  have  of  course  their  moral 
phase,  precisely  as  they  have  an  economic  or  an  ethical  or  a  social 
or  a  medical  pha^e;  but  the  effort  to  mix  the  standards  of  moral 
judgment  with  the  medical  issues  of  detection  and  treatment  of  the 
two  diseases  persistently  befuddles  thought  and  blocks  the  waiting 
forces  of  progress. 

Confusion  with  the  ProMem  of  Prostitution. — The  second  fallacy 
is  the  confusing  of  the  problem  of  the  genital  infections  with  that 
of  commercialized  vice.  To  this,  the  false  and  misleading  label 
''social  evil"  and  its  twin  sister  "social  diseases"  have  contributed 
liberally.  The  situation  is  essentially  that  of  mistaking  the  part 
for  the  whole.  No  one  would  seek  to  deny  that  commercialized  vice 
is  a  large  factor  in  the  distribution  of  syphilis  and  gonorrhea.  Med- 
ically speaking  it  can  be  thought  of  as  the  intermediate  host  or  car- 
rier of  the  Spirochaeta  pallida,  just  as  the  mosquito  is  host  for  the 
malarial  parasite.  No  rational  public  action  against  malaria  neg- 
lects the  destruction  of  the  mosquito  and  the  swamps  in  which  it 
breeds.  Yet  is  that  any  reason  why  we  should  ignore  mosquito 
netting  to  prevent  its  access  to  the  body,  or  quinine  to  destroy  the 
germ  when  once  it  enters  the  blood?  Point  for  point,  the  rational 
outlook  on  syphilis  should  match  that  on  malaria.  Because  we  have 
indeed  found  it  unexpectedly  difficult  and  perhaps  impossible  total- 
ly to  destroy  the  prostitution  host,  is  that  an  intelligent  argument 
against  the  use  of  preventatives  upon  those  who  have  been  exposed 
to  danger  of  acquiring  syphilis  and  gonorrhea,  or  of  curatives  on 
those  who  have  become  infected  ?  No  clear-thinking  man  or  woman 
who  is  familiar  with  the  problem  expects  the  immediate  extinction 
of  all  mosquitoes  or  all  prostitutes.  Yet  no  clear  thinker  expects 
this  difficulty  to  block  all  advance,  and  no  forward-looking  mind  is 
willing  to  see  the  day  of  racial  health  and  soundness  of  mind  and 
body  delayed  indefinitely  by  it.  Military  strategy  under  Marshal 
Foch  has  taught  us  that  many  blows  and  many  points  of  attack 
make  victory.  It  is  German  obtuseness  in  a  public  health  campaign 
against  syphilis  and  gonorrhea  to  push  away  in  shortsighted  dog- 


106 

gedness  at  the  obstacles  in  the  fields  of  prostitution,  to  the  exclusion 
of  all  other  forms  of  effort.  An  offensive  which  covers  the  other 
strategic  points  as  well,  carries  a  much  larger  prospect  of  success. 

Exaggerated  Notions  Ahout  Contagiousness. — Exaggerated  no- 
tions about  the  contagiousness  of  syphilis  and  gonorrhea  have  per-' 
formed  to  some  extent  for  these  diseases  though  to  a  less  degree,  the 
disservice  that  they  have  for  leprosy.  In  leprosy  the  issue  has  been 
less  productive  of  tragedies  because  of  the  comparative  rarity  of 
the  disease.  In  syphilis  because  the  disease  is  so  much  more  com- 
mon, false  notions  have  worked  deep  and  embittering  injustice. 
Some  of  the  situations  have,  however,  the  merciful  quality  of  being 
ludicrous.  The  development  of  hospital  services  for  the  treatment 
of  the  disease  is  replete  with  anecdotes  that  there  is  no  space  to 
repeat.  I  have  known  eminent  medical  gentlemen  to  wash  their 
hands  with  almost  hysterical  eagerness  after  touching  my  door 
knob,  or  after  the  presentation  of  one  of  my  cases  in  a  clinic;  and 
nurses  and  office  assistants  joining  my  staff  to  be  the  recipients  of 
condolences  from  friends  and  tearful  protests  from  relatives;  the 
supposedly  well-informed  heads  of  training  schools  to  refuse  me 
nurses  when,  without  their  realizing  it,  I  had  identified  for  them 
repeatedly  the  dangerously  contagious  syphilis  which  they  were 
unconsciously  nursing  in  their  wards  and  in  their  finest  private 
rooms.  Of  the  uninformed  we,  of  course,  expect  such  blunders. 
That  similar  types  of  thinking  are  still  prevalent  among  the  flower 
of  the  profession  is  only  a  tribute  to  the  super-darkness  that  sur- 
rounds us.  We  who  are  laborers  in  this  field,  look  forward  to  the 
day  when  toilet  and  bath,  door  knob,  effluvium  and  invisible  con- 
tagion will  retreat  from  the  foreground  of  the  public  thought  and 
give  place  to  rational  comprehension  of  the  bacteriology,  the  hygiene 
and  the  epidemiology  of  syphilis  and  gonorrhea. 

The  Fallacy  of  Believing  Fear  a  Deterrent. — With  the  fourth  ele- 
ment in  j)ublic  misconception  we  enter  a  field  for  thought.  The  be- 
lief is  exceedingl}'  common  that  the  fear  of  acquiring  syphilis  or 
gonorrhea,  if  widely  enough  spread,  will  deter  those  who  would 
otherwise  seek  unsocial  sexual  gratification.  No  unequivocal  an- 
swer to  the  argument  can  be  offered.  On  one  side  of  the  question, 
however,  it  can  be  given  as  the  experience  of  many  workers  in  this 
field,  myself  among  the  number,  that  the  popular  impression  is  a 
delusion.  As  a  student  of  this  question  for  a  number  of  years,  and 
at  times  a  speaker  upon  it,  I  have  been  unable  to  convince  myself 
that  fear  stands  effectively  between  a  man  and  the  gratification  of 
his  sexual  desire.  Of  the  many  fairly  well-informed  sexual  offend- 
ers that  have  passed  through  my  hands,  T  can  scarcely  recall  one 
who  did  not  believe  himself  skillful  enough  to  evade  trouble,  or  the 


107 

possessor  of  some  talismanic  key  to  a  situation  or  who  did  not  go 
ahead,  risk  or  no  risk,  in  response  to  imperious  desire.  It  is  not 
cynicism  to  rate  the  efl&cacy  of  horror  so  low.  Horror  is  cheap,  and 
makes  a  feeble  and  unworthy  substitute  for  ideals.  A  reasonably 
brisk  talker  with  colored  lantern  slides  can  pile  horror  on  horror  un- 
til it  bulges  from  the  windows  and  through  the  doors,  and  the  pause 
between  impressive  sentence  and  impressive  sentence  is  punctuated 
by  the  collapse  of  the  weaker  members  of  the  crowd.  During  the  next 
few  months  after  such  a  presentation  the  observer  behind  the  lines 
meets  distracted  members  of  the  audience  in  the  consulting  room 
and  wrestles  with  them  to  undo  the  damage  inflicted  by  a  mode  of 
approach  that  did  not  prevent  subsequent  infection,  but  simply 
superimposed  upon  it,  nervous  prostration.  Knowledge  of  disas- 
trous consequences,  and  fear  of  syphilis  particularly,  is  now  an  old 
story  to  quite  a  number  of  young  men.  Medical  students,  who  know 
all  about  it,  have  no  monopoly  of  virtue.  Syphilis  and  gonorrhea 
have  long  ofl&ciated  in  the  role  of  morals  policemen.  They  have 
never  shown  evidence  of  enough  efficiency  in  the  form  of  a  reduc- 
tion of  the  rate  of  exposure  to  justify  their  tremendous  cost  to  the 
world. 

A  Positive  Idealism  Necessary. — Bishop  Lawrence  in  one  of  his 
addresses^  touched  the  vital  point  in  fear  as  a  deterrent.  In  a  day 
when  the  Christian  church  is  at  last  learning  the  virtues  of  a  posi- 
tive idealism  and  has  ceased  to  preach  hell  as  a  means  toward 
heaven,  it  is  a  tawdry  morality  that  would  found  the  new  moral 
responsibility  in  sexual  life  upon  fear.  It  is  a  degrading  and  un- 
worthy monogamy  whose  slogan  is  only  prudence,  and  whose  bul 
wark  of  defense  co'nsists  of  the  pitifully  broken  and  twisted  human 
wreckage,  the  shorn  innocence,  the  dismembered  helplessness  piled 
up  by  syphilis  and  gonorrhea  in  the  masquerade  of  spiritual  defense. 
On  honor  and  social  responsibilitj^  and  not  on  enlightened  cowardice 
will  be  squarely  placed  the  burden  of  the  sex  ethics  of  the  future. 

^^T  Thank  Thee  That  I  Am  Not  as  Other  Men  Are." — A  certain 
Pharisaical  self-righteousness  underlies  too  much  of  our  public 
thought  about  syphilis  and  gonorrhea.  '"Diseases  of  vice,"  ''the 
underworld,"  "such  patients,"  "that  kind  of  work,"  represent  types 
of  thought  that  are  tinged  with  it.  Like  the  "erring  brother"  type 
of  missionary  spirit,  it  defeats  itself.  Nothing  was  ever  gained  by 
undiscriminating  "sob  stuflE"  of  the  "fallen  woman"  order.  It  has 
been  my  personal  duty,  and  often  my  privilege  to  know  the  inti- 
macies of  the  lives  of  many  types  of  victims  of  the  genital  infections, 
and  I  have  yet  to  meet  a  "fallen  woman."  Some  of  them  are 
mentally  abnormal,  some  of  them  tough,  the  women  tonglier  thnn 

J  Social  Hygiene,  1918,  iv,  317. 


108 

the  men  sometimes,  but  at  bottom  a  curious  streak  of  the  square 
deal  still  persists.  Through  all  their  wobblings  and  gropings,  their 
weakness  and  blindness,  their  egregious  vanity  and  towering  ego- 
tism, their  unsocial  minds  and  spineless  irresponsibilities,  there  still 
moves  something  which  makes  them  human.  With  many  of  them 
their  condition  is  a  sickness,  not  a  vice.  They  cling  to  friendship 
pathetically,  honor  can  move  them,  and  love  may  lead  them  when 
honor  fails.  There  is  no  man  or  woman  of  grace  and  distinction 
who  need  feel  that  an  acknowledgment  of  brotherhood  with  these 
will  precipitate  one  from  the  heights.  It  is  not  necessary  in  the 
exercise  of  a  larger  charity  to  swing  to  the  extreme  of  maudlin 
sentimentality.  After  all,  thinking  men  and  women  can  ask  them- 
selves the  really  fundamental  question  about  their  attitude  toward 
syphilis  and  gonorrhea:  "Do  I  think  myself  holier  than  thou?" 
Christ  laid  the  simple  foundations  of  a  noble  ethic  in  His  word  to 
the  woman  taken  in  adultery,  "Neither  do  I  condemn  thee — go,  and 
sin  no  more." 

Syphilis  and  Gonorrhea  as  ^^ Fright  fulness/' — And  in  the  final 
group  of  obstructionists  we  number  that  fellowship  of  the  apostles 
of  f rightfulness  who  believe  that  syphilis  and  gonorrhea  are  punish- 
ments for  sin.  To  these,  the  "Gott-strafers,"  we  owe  a  truly  fiend- 
ish conception  of  the  two  diseases,  that  of  disgrace  and  stigma. 
The  mother  on  her  deathbed,  dying  of  gonorrheal  puerperal  sepsis 
while  two  nurses  and  a  doctor  fight  for  the  baby's  eyes,  is  disgraced. 
The  boy  with  a  chancre  who  came  in  to  offer  himself  as  a  subject  for 
experiment,  if  it  cost  him  his  life — he  had  been  filled  up  with  liquor 
by  companions,  and  infected — he  is  disgraced.  There  is  the  mother, 
half  her  children  in  the  grave,  a  third  of  the  rest  in  hospital  and 
asylum,  taking  in  washings  to  hold  the  family  together  and  to  fill 
the  place  of  the  husband  who  died.  Her  twisting  face,  and  shaking 
chin,  and  catching  throat  beg  you  to  tell  her  she  has  a  fatal  cancer 
rather  than  "the  bad  disease" — yes,  she  is  disgraced,  too.  And 
there  is  the  girl  who  trusted  him,  and,  too,  the  boy  who  trusted  her, 
and  the  man  who  in  an  hour  of  loneliness  met  folly  once — the  "Gott- 
strafers"  lump  them  all  in  Limbo  with  the  stage-door  Johnny  and 
the  hotel  tout,  the  cop  who  takes  his  pay  in  trade,  the  pimp  and  the 
professional  seducer.  Leaving  the  humanity  of  it  out  of  the  ques- 
tion and  speaking  medically  the  crushing  effect  of  the  sense  of  dis- 
grace breaks  many  a  patient  whom  the  disease  would  scarcely  touch. 
And  it  is  not  the  patient  who  deserves  it,  that  meets  this  fate.  The 
hardened,  the  vicious,  laugh  it  off  as  part  of  the  hazard  of  the  game. 
It  is  the  innocent,  the  sensitive,  the  timid,  the  shrinking,  the  child- 
like who  are  crushed.  Analysis  again  comes  to  our  rescue.  Syph- 
ilis and  gonorrhea  have  all  the  characteristics  of  the  famous  German 


109 

frightfulness.  They  make  no  pretense  of  discrimination  between 
innocent  and  guilty.  They  are  non-educative  and  non-reformatory. 
They  murder  non-combatants.  They  inflict  barbarities  which  for 
refined  atrociousness  can  put  the  best  efforts  of  kultur  into  the 
background.  They  are  indeed  worthy  of  the  "Gott-strafe"  mind, 
which  adopts  them  as  punishments  for  sin. 


CHAPTER  il. 

NORMAL  IDEALS  OF  THE  SEX  LIFE.     ABNORMAL  CHECKS  ON 

MARRIAGE.    THE  TREND  OF  THE  TIMES  TO  LAXITY. 

THE  INFLUENCE  OF  THE  WAR. 

The  Normality  of  Sew  Ideals. — The  day  of  calmer  thinking,  less 
prurience,  fetichism  and  taboo,  will  see  a  reconstruction  of  our  con- 
ceptions of  the  sexual  life.  The  instinct  to  reproduce  has  as  great 
a  normality,  as  high  a  title  to  consideration  and  intelligent  adjust- 
ment as  does  the  passion  for  enough  to  eat,  which  is  simply  an  ex- 
pression of  the  metabolic  needs  of  the  protoplasm  of  which  we  are 
made.  The  tendency  to  strain  at  sexual  gnats  and  swallow  com- 
mercial, ethical  and  political  camels  is  as  common  as  it  is  alter- 
nately laughable  and  tragic.  Fundamental  principles  of  equity, 
justice,  mercy  and  unselfishness  underlie  this  part  of  our  lives  as 
truly  as  they  do  the  dealings  in  our  courts  of  law,  our  business  or- 
ganizations, our  hospitals,  our  social  settlements.  The  future  is  in 
the  hands  of  those  who  can  read  into  the  heretofore  distorted  and 
primitive  narrowness,  the  prurient  self-consciousness  of  society 
about  sex,  a  broader  and  more  generous  interpretation.  It  is  equal- 
ly in  the  hands  of  those  who  can  balance  a  liberal  tendency  with  far- 
sighted  idealism,  who  can  temper  generosity  with  fairness  and  free- 
dom with  responsibility. " 

The  Changing  Trend  of  Sex  Ideals. — The  student  of  the  sexual  life 
in  its  relation  to  problems  of  public  health  cannot  escape  a  sense 
of  impending  great  revisions.  Murmurings  and  intimations  float 
about,  social  investigations  from  time  to  time  give  definite  shape  to 
impressions.  No  one  would  be  so  rash  as  to  predict  the  cataclysmic, 
but  it  is  hard  to  avoid  the  belief  that  reconstruction  is  on  us  whetli- 
er  we  will  or  not.  Moral  codes  that  are  ultrabiologic  will  plunge 
us  into  muck.  On  the  other  hand,  moral  codes  that  consist  of  a 
thin,  attenuated  and  bloodless  idealism  which  would  convert  the 
sexual  relation  from  a  love  expression  into  a  stock-breeder's  device 
for  the  fertilization  of  the  human  female,  liave  an  even  smaller 
chance  of  shaping  our  future.  It  must  be  a  primary  aim  of  any 
movement,  public  health,  ethical,  or  whatnot,  if  it  deals  ^ith  sex, 
to  combine  ideals  and  practicality'  into  a  standard  of  conduct  which 
best  expresses  the  fundamental  and  all-inclusive  principles  of  love, 
honor,  and  responsibility. 

Growing  Need  for  a  Bulirark  of  Moral  Ideals. — The  need  for  con- 
sidering tlie  future  of  sex  othics  carries  witli  it  the  demand  for  a 
frank  analysis  of  our  present  situation.  Tlie  prevention  of  syphilis 
and  gonorrhea  will  have  direct  effect  in  throwing  luiman  sexual  life 
back  upon  its  ethical  essentials.     If  disease  were  to  be  I'eiuoved  from 


Ill 

the  field  of  "accidents"  and  Avliat  little  preventative  influence  it  pos- 
sesses were  to  cease  to  be,  then  moral  standards  would  take  their 
true  places,  as  the  only  real  character-forming  bulwark  between  the 
social  order  and  unrestrained  gratification  of  sex  impulses.  But 
in  the  last  ianalysis,  the  hold  of  such  moral  standards  upon  the  race 
will  be  proportional,  not  to  the  depth  of  the  social  frown  which  pun- 
ishes their  violation,  but  to  their  inherent  nobility,  reasonableness 
and  justice.  It  is  at  least  good  policy  to  believe  that  a  self-enforcing 
sexual  moral  code  will  rest  primarily  upon  such  a  foundation. 
Only  by  so  doing  can  it  lio]ie  to  appeal  to  a  sufficiently  large  body 
of  humanity  to  make  social  disapproval  of  unsocial  behavior,  eff'ec- 
tive.  The  first  necessity  for  the  development  of  such  a  code  is  a 
consciousness  of  the  weaknesses  of  the  existing  system. 

Remediable  Obstacles  and,  Factors  of  Error  in  Marriage. — Mar- 
riage, the  accepted  convention  for  the  gratification  of  the  human 
sexual  impulse  and  its  utilization  as  an  inspirational  force,  has  not 
yet  reached  its  ultimate  perfection.  It  is  urged  as  an  outlet  for  the 
sexual  ardor  of  young  men  and  young  women.  Under  existing  con- 
ditions it  has  too  high  a  margin  of  error  for  a  scientific  method,  too 
large  a  factor  of  wastage  for  an  efficient  piece  of  economic  ma- 
chinery. It  is,  of  course,  no  reproach  upon  an  ideal  such  as  we 
cherish  for  marriage  to  say  that  it  is  high.  Any  reproach  comes  in 
allowing  its  institutional  expression  to  be  so  beset  with  obstacles  and 
factors  of  error  that  it  becomes  unattainable,  or  a  punishment  and  a 
discipline  rather  than  a  compensation,  an  outlet,  and  a  worthy  ex- 
pression of  human  nature.  In  the  same  way,  continence,  as  a  sex 
ideal  for  the  unmarried,  is  invaluable  in  preparation  for  normal 
marriage.  Yet  there  are  those  who  seem  to  feel  that  as  a  means  of 
keeping  worth-while  men  and  women  unfulfilled  and  childless  be- 
cause of  the  impossible  demands  of  an  oppressive  social  order,  it 
deserves  even  less  attention  than  it  gets.  Between  these  two  ex- 
tremes there  lies  a  middle  course,  dictated  by  a  combination  of 
idealism  and  common  sense.  The  idealism  is  summed  up  in  the 
words  love,  honor,  responsibility.  No  institution  or  code  which 
adequately  translates  all  three  into  practice  need  be  distrusted. 
Common  sense  consists  in  the  recognition  of  the  fact  that  a  social 
order  which  offers  neither  training  nor  inducement  for  its  author- 
ized sexual  practice;  which  makes  it  economically  prohibitive  and 
unattainable  in  one  way  or  another  for  a  liberal  percentage  of  com- 
mon humanity  and  makes  it  acutely  painful  and  punitive  for  an- 
other portion,  must  revise  its  methods  or  meet  disaster. 

Training  in  the  Ideals  and  Practicalities  of  Marriage. — It  is  worth 
while  to  be  briefly  enumerative  of  certain  aspects  of  the  problem 
of  increasing  the  practicality  of  the  conventional  sexual  life,  in 


112 

order  to  inspire  those  who  have  the  opportunity  to  think  and  speak 
to  thought  and  speech.  In  the  first  place,  only  in  indirect  ways 
are  the  idealism  of  marriage  and  the  ways  of  making  those  ideals 
practical,  taught  to  children.  If  marriage  is  to  constitute  the  whole 
outlet  for  an  instinct  as  fundamental  as  the  securing  of  food,  it 
should  be  taught  with  the  same  assiduity  and  even  greater  skill 
and  foresight  than  goes  into  the  learning  of  a  life-work,  Not  only 
should  girls  learn  its  economics,  but  they  should  learn  its  theory, 
its  ethics,  its  arts.  Boys  should  learn  side  by  side  with  the  business 
training  of  the  paper  route,  and  the  physical  training  of  the  gym- 
nasium, the  disciplinary  give  and  take,  the  chivalrous  gentleness 
that  fits  them  to  be  fathers  and  husbands. 

Marriage  and  Industrial  Dependence. — As  long  as  marriage  spells 
economic  slavery,  it  will  be  an  unworthy  expression  of  human  ideals. 
If  it  cannot  be  made  to  appeal  to  the  healthy-minded  woman  of  the 
future  on  other  than  economic  grounds  it  lacks  something.  If  tne 
woman  feels  that  marriage  is  a  descent  into  domestic  drugery  from 
an  elevation  of  industrial  independence  she  will  not  be  long  in  find- 
ing a  way  to  combine  the  independence  of  industry  with  marriage 
minus  drudgery.  What  such  a  combined  institution  might  be,  it  is 
impossible  to  predict.  In  many  talks  with  different  types  of  women 
the  author  has  received  impressions  of  the  future  varying  from  a 
liaison  for  sexual  pleasure  to  virtually  sexless  business  partner- 
ships, and  platonic  friendships.  These,  of  course,  represent  ex- 
tremes. There  is  no  question,  however,  that  the  "meal-ticket"  hold 
of  feminine  economic  dependence  in  marriage  is  slipping,  and  with  it 
will  go  a  force  for  which  an  adequate  substitute  in  idealism  will 
have  to  be  found.  Where  it  is  lacking,  an  ill-judged  union  will  end 
in  speedy  separation,  and  the  creation  of  two  sexual  appetites  to  be 
satisfied  instead  of  one,  since  sexual  experience  when  once  had,  tends 
to  break  down  the  bonds  of  self-restraint.  Stringent  divorce  laws 
will  have  less  than  their  present  trifling  effect  in  controlling  the 
situation,  since  the  refusal  of  divorce  where  both  sides  are  inde- 
pendent merely  serves  as  a  means  of  inciting  to  clandestinism  and 
concubinage. 

The  Effect  of  Failure  on  Marriage  Ideals. — The  unsuccessful  mar- 
riage per  se  has  probably  no  more  effect  under  existing  conditions 
in  deterring  others  from  marrying  than  has  fear  in  preventing 
sexual  indulgence.  Again  each  pair  believes  itself  possessed  of  a 
talismanic  key  to  the  situation.  Yet  in  the  end,  the  high  percent- 
age of  blighted  unions  has  an  unfavorable  effect  upon  the  conven- 
tional form  of  sexual  expression.  One  sees  what  appears  to  be  an 
increasing  tendency  to  "try  it  out,"  which  must  be  considered  and 
aligned  with  the  future  of  the  sexual  life.     My  own  impressions 


113 

have,  for  instance,  repeatedly  confirmed  the  observations  of  Woods 
and  Kennedy^  among  working  girls  and  men,  upon  the  growing 
popularity  of  an  unoflQcial  form  of  sexual  union,  a  liaison  which 
may  or  may  not  end  in  marriage,  according  to  the  inclination  of  the 
parties  or  the  incidence  of  a  complication  such  as  pregnancy.  The 
vogue  and  the  rationale  of  such  a  trial  marriage  should  be  the  object 
of  careful  social  study,  with  a  view  to  ascertaining  its  idealistic 
basis,  which  is  often  higher  than  rigorous  convention  admits,  and 
to  diverting  it  into  social  channels.  As  a  distinguished  landscape 
architect  once  remarked  to  a  college  group  apropos  of  the  laying  out 
of  paths  between  buildings  on  a  campus  "we  watch  the  movements 
of  the  students  across  the  grounds  and  allow  them  to  influence  to 
some  extent  the  lines  along  which  we  lay  cement."  A  similar  atti- 
tude always  properly  guarded,  has  its  place  in  determining  the  in- 
stitutional future  of  human  sexual  life. 

Marriage  and  the  Economic  Treadmill. — Economic  obstacles  are 
a  grave  menace  to  the  future  of  marriage  as  the  solution  of  the  prob- 
lem of  human  sexual  relations.  The  almost  cynical  indifference  of 
the  state  to  one  of  the  most  vital  of  human  functions  and  one  which 
more  than  any  other  involves  its  own  perpetuation  is  one  of  the 
social  anomalies  of  our  times.  Apart  from  using  the  portal  of 
entry  into  marriage  as  a  fee  collecting  mill,  and  barring  the  exit 
from  many  a  spiritual  catastrophe,  the  state  gives  the  relation  mini- 
mal attention.  Marriage  in  these  days  depends  too  much  on  being 
able  to  meet  the  extortionate  cost  of  living  for  two  and  the  children, 
and  too  little  on  physical  or  spiritual  fitness  for  the  perpetuation 
of  the  race.  In  some  way  an  equitable  basis  must  be  found  for 
making  the  raising  of  a  family  an  industry,  with  adequate  rewards 
proportionate  to  its  success.  The  special  worker  with  the  genital 
infections  has  more  than  enough  opportunity  to  appreciate  the 
force  of  the  answer  he  gets  from  likely  young  men  in  response  to  his 
question  "Why  don't  you  marry?"  A  statement  of  earning  capacity 
and  the  response  "Would  you  ask  a  girl  to  marry  you  on  that  much, 
in  these  days?"  is  only  too  often  answered  by  a  reluctant  "No." 
Early  marriage  of  all  things  is  the  most  completely  out  of  harmony 
with  the  existing  economic  order,  while  it  seems  the  only  available 
solution  within  existing  conventions,  of  the  problem  of  sexual  life. 
When  a  man's  sexual  ardor  and  value  are  greatest,  he  should  marry ; 
but  to  do  so,  too  often  chains  himself  and  the  girl  to  the  treadmill 
of  economic  bondage.  The  advice  has  so  little  of  practicality  in  it 
under  present  conditions  that  those  who  undertake  to  follow  it  to- 
day are  regarded  as  painfully  and  even  questionably  romantic.  They 


1  Woods.    R.,    and    Kennedy,    A. :    Young    workinjr    Rirls.     Evidence    of    2000    social 
worJjers.     Boston,  Houghton.  1913.     Price  $1.00. 


114 

are  certainly  not  de  t~igeur,  and  have  a  place  as  objects  of  com- 
miseration. Until  the  father  believes  the  son's  and  daughter's  suc- 
cessful and  reasonably  early  marriage  to  be  fully  as  significant  as  a 
college  commencement,  and  is  willing  to  provide  for  it;  until  the 
state  subsidizes  healthy  motherhood  and  childhood  substantially, 
without  waiting  for  parentage  to  be  crowned  with  widowhood ;  until 
we  realize  that  to  talk  marriage  as  a  sexual  solution  and  then  post- 
pone it,  is  to  deal  in  farce,  the  problem  of  an  adequate  sexual  life 
as  a  protection  against  unsocial  gratifications  remains  unsolved. 

The  Tendency  of  Sex  Life  to  Crudity  of  Expression. — It  is  the 
fashion  in  these  days  to  rend,  not  lift  the  veil.  By  this  phrase  I 
nean  to  put  a  hopeful  construction  on  the  modern  habit,  not  yet  at 
i  ts  climax,  of  making  sexual  issues  the  currency  of  everyday  thought 
and  speech.  We  have  seen  the  period  of  irrational  silence  and  ro- 
straint.  We  are  moving,  it  seems  to  me,  with  equal  certainty  upon 
the  period  of  over-expression.  The  tendency  to  think,  to  talk,  to 
read  sex  problems  on  every  side  creates  an  impression  that  every- 
body acts  them,  that  there  is  a  trend  of  the  times  to  license.  While 
some  of  the  trouble  is  mere  noise  and  some  is  simply  uncouthness, 
there  is  a  noticeable  abandonment  of  the  dignity  which  should  mark 
a  new  idealism  and  guard  its  translation  into  practice.  Of  course, 
we  want  no  more  whispers,  no  more  lies,  false  names,  wriggling 
and  squeamish  prudishness.  But  force  is  not  incompatible  with 
dignity,  and  frankness  with  a  discriminating  choice  of  words. 
More  than  one  ardent  spirit  has  been  chastened  by  the  apprecia- 
tion that  he  might  have  spread  the  new  knowledge  better  if  he  had 
done  it  less  crudely.  That  the  truth  needs  lucidity  rather  than  ex- 
pletives is  a  maxim  that  the  ablest  thinker  on  sex  questions  can 
afford  to  recall. 

The  Trend  toivard  Sexual  Laxity;  Decadence  of  Chaperonage. — 
To  my  mind,  much  of  the  real  trend  of  the  times  to  sexual  laxity 
as  distinguished  from  mere  noise,  lies  in  the  decadence  of  home 
influence  as  illustrated,  let  us  say,  by  the  decline  of  chaperonage. 
We  forget  so  easily,  as  I  shall  take  occasion  to  say  again,  that 
knowledge  per  se  is  little  protection  unless  reinforced  by  judgment. 
The  home  must  in  childhood  and  adolescence,  supply  judgment. 
No  one  can  read  and  see  verified  in  daily  life  such  a  series  of  thumb- 
nail sketches  as  Kautfman's  "Girl  That  Goes  Wrong"^,  without  re- 
alizing that  there  is  no  substitute  for  the  guardianship  of  experi- 
ence over  the  rashness,  the  impulse  and  the  unsophistication  of 
youth.  Such  guardianship,  without  being  tyrannical,  must  extend 
to  many  little  things,  which  the  relaxations  of  our  day  regard  as 
trivial.    In  conversation  with  a  noted  prostitute,  herself  a  woman 

>  Kauffman,  R.  W. :  The  girl  tli;it  goes  wrong-.     Ne\Y  York,  Moffat,  Yard,  1911. 


115 

of  more  than  average  cultivation  and  insight,  she  rated  the  young 
girl's  habit  of  dining  out  unchaperoned  with  men  as  one  of  the 
most  potent  contributing  factors  to  illicit  sexual  experience.  In 
the  same  class  go  the  unsupervised  automobile  jaunt,  and  the  ac- 
tivities of  the  taxicab,  which  are  writing  a  new  chapter  into  the 
sexual  history  of  the  day.  There  is  little  time  for  mention  of  more 
than  principles,  though  each  observer  can  discover  a  new  illustra- 
tion for  himself.  The  same  point  stands  out  through  all  of  them. 
The  decadence  of  adult  oversight  for  boys  and  girls  alike,  is  throw- 
ing back  upon  the  most  ardent,  least  sophisticated,  least  experi- 
enced and  therefore  least  competent  period  of  life,  sex  decisions 
of  more  than  vital  moment  to  the  race. 

Contributions  Made  ty  the  Wct/r  to  Sex  Problems. — Upon  prob- 
lems of  sexual  conduct  the  war  has  already  shown  evidence  of  four 
important  iniiuences.  The  first  of  these  is  the  full-fledged  entry  of 
women  upon  the  stage  of  industry  and  economic  independence.  As 
I  have  already  intimated,  profound  modification  of  the  relation  of 
husband  and  wife  may  result  from  it.  The  second  influence  may 
come  through  the  general  spread  of  knowledge  on  medical  means 
of  preventing  syphilis  and  gonorrhea.  Millions  of  men,  literally, 
have  been  educated  to  it  by  army  methods,  and  broadcast  public 
teaching  on  the  subject  has  been  carried  out  in  Italy  and  Germany 
at  least.  Whether  or  not  there  shall  be  a  medical  prevention  of  the 
genital  infections  has  ceased  to  be  a  matter  for  discussion.  It  is 
here,  and  the  next  problem  is  its  proper  utilization  and  control. 
The  knowledge  is  good,  but  again,  its  application  needs  judgment 
and  must  be  begun  before  the  flood  of  it  engulfs  us.  The  third  in 
fluence  comes  through  the  tremendous  contributions  of  the  war  to 
the  idealistic  solution  of  sex  problems.  The  questions  of  the  ef 
ficiency  of  intelligent  sex  education,  of  the  repression  of  vice,  of  the 
ability  to  keep  up  sexual  morale  by  indirect  influences  such  as  recre- 
ation and  the  increasing  of  the  livableness  of  life,  are  settled  past 
all  dispute.  The  fourth  influence  is  being  exerted  through  the 
awakening  of  the  world  from  lethargic  indifference  to  a  sense  of 
public  duty  in  connection  with  sexual  issues.  The  spectacle  of 
governments  bending  their  energies  to  the  solution  of  the  problem 
of  syphilis  and  gonorrhea  would  astonish  our  great  grandfathers  no 
less  than  would  the  electric  motor,  the  locomotive  and  the  wireless 
telegraph. 


116 

CHAPTER  III. 

THE  ECONOMIC  BACKGROUND  OF  SYPHILIS  AND  GONORRHEA. 
PROSTITUTION.  ALCOHOLISM  AND  THE  GENITAL 
INFECTIONS.  OTHER  FORMS  OF  COM- 
MERCIAL EXPLOITATION. 

The  Dollars  and  Cents  Aspect. — In  the  earlier  days  of  the  cam- 
paign against  tuberculosis,  some  very  ingenious  methods  were  re- 
sorted to  in  order  to  impress  the  public  with  the  fabulous  losses  in 
actual  dollars  and  cents,  occasioned  by  this  disease.  No  comprehen- 
sive figures  are  at  present  available  for  syphilis  and  gonorrhea.  Most 
of  the  evidence  bearing  upon  the  economic  cost  of  syphilis  is  buried 
among  the  statistics  of  insane  h6spitals  and  pauper  institutions. 
Only  occasional  glimpses  can  be  had,  which  indicate  the  enormous 
wastage  which  they  cause.  Williams  estimated,  it  will  be  recalled, 
that  ten  men  insane  from  syphilis,  represented  a  net  loss  based  on 
life  expectancy  of  |212,248  in  earning  capacity,  and  a  cost  to  the 
State  of  Massachusetts  of  |39,312.  According  to  the  census  of 
1910  there  were  180,000  insane  persons  in  the  United  States.  Esti- 
mating 12  per  cent  of  insanity  to  be  due  to  syphilis  and  the  experi- 
ence of  Massachusetts  to  be  applicable  to  the  country  as  a  whole, 
the  economic  loss  in  earning  capacity  and  cost  of  care  on  the  score 
of  a  single  item  in  the  total  bill  of  only  one  of  the  genital  infections, 
would  approximate  |467,000,000.  If  insanity,  a  relatively  uncom- 
mon complication  of  syphilis,  can  alone  cost  more  than  a  half  bil- 
lion dollars,  the  cost  of  illness  and  death  from  other  and  equally 
grave  complications,  such  as  heart  and  kidney  disease,  blindness, 
deafness,  paralysis  due  to  nervous  change,  when  added  together,  will 
total  figures  that  take  rank  beside  the  stupendous  costs  of  war. 
These  are  estimates  of  the  cost  of  consequences.  The  wastage  of 
money  spent  on  ineffective  treatment,  on  the  maintenance  of  hos- 
pitals and  dispensaries,  on  medical  fees,  and  through  reduction  of 
efficiency  without  absolute  crippling  and  death,  is  beyond  the  r^fich 
of  comprehension. 

Current  legislative  appropriations  which  provide  for  little  more 
than  scratching  the  surface  of  the  problem  of  prevention,  vary  from 
160,000  to  1100,000  in  certain  states,  to  the  $2,700,000  provided  for 
one  year's  work  on  the  part  of  the  national  government.  In  1914  it 
was  estimated  that  |400,000  would  merely  provide  salvarsan  for  the 
British,  without  any  consideration  of  the  cost  of  giving  it.  The 
United  States  Navy  on  a  single  invoice  of  salvarsan  paid  a  bill  of 
?^17,000.  Sums  such  as  these  could  in  the  aggregate  within  a  gen- 
eration make  an  appreciable  showing  on  the  part  of  one  disease, 
even  as  against  the  colossal  figures  of  war  finance. 


117 

Cost  of  Treatment  as  an  Element  in  the  Campaign. — The  cost  of 
the  treatment  of  syphilis  or  gonorrhea  is  a  practical  issue  of  the 
first  magnitude  in  a  public  health  campaign.     Modern  treatment  of 
either  of  these  diseases  calls  for  prolonged  medical  attention,  and 
in  the  case  of  syphilis  especially,  for  expensive  drugs  and  tests. 
The  expert,  who  is  best  fitted  to  cope  with  them,  is  an  expensive 
man,  who  has  had  one  of  the  long  and  costly  trainings  so  charac- 
teristic of  medicine  of  today.    Few  patients  of  moderate  means  are 
adequately  treated  for  a  secondary  syphilitic  infection  for  less  than 
$500.    With  complications  in  either  gonorrhea  or  syphilis  the  cost 
rises  rapidly  and  with  the  increasing  incapacity  which  many  of  them 
involve,  the  ability  of  the  patient  to  pay  for  good  service  rapidly 
declines.    Again,  the  large  majority  of  infections  are  acquired  early 
in  life,  before  the  victim    has  reached  an  earning  capacity  which 
will  enable  him  to  cope  with  the  situation.     The  result  is  that  he 
neglects  it,  and  loses  the  opportunity  for  cure  for  which  in  later 
years,  as  successful  merchant,  banker,  public  official,  he  would  give 
all  he  has.     So  significant  is  the  cost  factor  in  the  public  health 
problem  of  syphilis  and  gonorrhea,  that  it  is  now  universally  recog- 
nized as  wise  policy  for  the  state  to  provide  free  treatment  for 
every  patient  who  cannot  meet  the  expense.     The  provision  of  such 
treatment  should  include  the  services  of  adequately  trained  men. 
The  sooner  the  state  commits  itself  to  a  policy  of  expert  service  in 
the  genital  infection  field,  the  sooner  will  results  appear.     It  is 
scarcely  to  be  imagined  that  highly  special  knowledge  of  this  sub- 
ject will  be  found  behind  every  doctor's  name  plate.     It  is  also  a 
gross  injustice  to  expect  men  who  have  met  the  expense  of  a  train- 
ing fully  as  prolonged  and  costly  as  that  of  the  traction  and  light- 
ing experts  and  legal  counsel  for  which  a  city  pays  so  lavishly,  to 
serve  with  inadequate  compensation  in  hospitals  and  dispensaries. 
Such  a  system  in  connection  with  medical  schools  and  public  medi- 
cal facilities  leads  to  worthless  service  and  to  forms  of  graft  no  less 
obnoxious  than  those  of  politics.    Until  medical  schools  and  hos- 
pitals are  prepared  to  place  the  care  of  syphilis  and  gonorrhea  in 
the  hands  of  properly  qualified  and  paid  experts,  who  receive  appro- 
priate recognition,  for  their  ability  as  teachers  and  physicians,  a 
most  important  field  of  progress  against  these  diseases  will  remain 
closed. 

Commercialization  of  the  Sex  Impulse. — A  powerful,  constantly 
exerted  force  in  human  affairs  will  inevitably  be  subjected  to  com- 
mercial exploitation,  precisely  like  a  source  of  physical  energy  such 
as  water  power.  Powerful  influence  will  be  brought  to  bear  to  meet 
an  existing  demand,  and  to  create  new  demand.  Simple  economic 
laws  like  these  govern  the  relation  of  prostitution  to  the  sex  life. 


118 

The  relation  has  no  secrets  and  lew  mysteries.  Take  the  money 
out  of  it  and  from  behind  it,  and  it  loses  a  large  part  of  its  hold  on 
the  world.  Similarly  the  relation  of  alcoholism  to  prostitution  and 
through  it,  to  syphilis  and  gonorrhea,  is  a  phase  of  commercial  ex- 
ploitation of  the  sex  impulse,  the  simple  selling  of  a  means  to  pro- 
mote hilarity  and  take  ofif  the  moral  brakes.  These  two  factors  in 
the  public  health  problem  of  syphilis  and  gonorrhea  are  so  im- 
portant that  their  fundamentals  must  be  considered  here. 

Syphilis  and  Gonorrhea  in  Prostitutes. — Sexual  relations  between 
men  and  women  of  easy  virtue  constitute  the  ultimate  source  of  the 
overwhelming  proportion  of  infections  with  syphilis  and  gonorrhea. 
There  is  on  the  whole  little  evidence  to  show  that  clandestine  differs 
markedly  from  public  prostitution  in  its  ability  to  infect  the  patron. 
In  fact  the  throwing  of  false  security  such  as  that  of  medical  ex- 
amination and  registration  about  the  better  organized  public  types, 
serves  to  make  them  more  rather  than  less  dangerous^.  Repeated 
careful  surveys  of  the  situation  have  brought  out  with  striking 
definiteness,  the  percentage  of  infection  which  exists  among  pros- 
titutes'. Gonorrhea  is  present  in  approximately  75  to  90  per  cent 
and  syphilis  in  60  to  80  per  cent  of  those  to  whom  promiscuous 
sexual  exposure  is  habitual.  Papee  showed  that  80  per  cent  of  the 
prostitutes  in  a  typical  city  (Lemberg)  were  in  the  first  to  third 
year  of  a  syphilitic  infection — that  is  in  its  most  contagious  period. 
Through  every  investigation  there  stands  out  the  fact  that  three- 
fourths  of  the  dangerous  cases  are  sexually  in  the  most  attractive 
period  of  their  lives — under  twenty-five  years  of  age^  The  number 
of  men  who  may  be  subjected  to  risk  of  infection  by  a  single  woman 
seems  incredible.  Conservative  German  estimates  during  the  war 
placed  the  activities  of  a  prostitute  at  forty  exposures  per  day,  and 
Exner  cites  a  case  on  the  Mexican  border  where  a  woman  with  ac- 
tive syphilitic  lesions  subjected  120  men  to  exposure  in  two  days. 
With  syphilis  and  gonorrhea  so  overwhelmingly  prevalent  it  is  dif- 
ficult to  understand  why  every  exposure  with  a  prostitute,  public 
or  private,  does  not  result  in  infection.  The  explanation  involves 
a  combination  of  chance,  presence  or  absence  of  contagious  lesions, 
the  stage  of  the  prostitute's  infection,  and  the  presence  or  absence 
of  favoring  conditions  in  the  partner  such  as  abrasions,  uncleanli- 
ness^  etc. 

The  Medical  Examination  of  Prostitutes. — The  general  descrip- 
tion of  the  medical  aspects  of  syphilis  and  gonorrhea  makes  it  ap- 
parent why  the  prevention  of  infection  in  prostitution   by  such 

1  Jolivet  found  in  a  recent  survey  thnt  52  per  ^ent  of  100  soldiers  had  been  infected 
by   registered,  48   per   cent  by   olaudestine   prostitutes. 

"Baltimore  Vi<>e  Commission.     Survey.  March   25,  l!)]f),  749. 

'  Philadelphia  Municipal  Court  Reports,  for  1!H(5,  for  example  (p.  260)  show  that 
150  of  214  girls  entered  prostitution  Ijetween  the  ages  of  twenty  and  twenty-four. 


119 

measures  as  the  medical  examinatiou  of  women  has  proved  a  failure 
under  the  conditions  of  ordinary  life.  A  woman  may  be  a  passive 
carrier  of  infection  from  a  previous  partner  without  herself  show- 
ing evidence  of  the  disease.  Examination  of  men  is  therefore  as 
much  in  order  as  that  of  women.  The  entire  intent  and  purpose 
of  a  medical  examination  for  gonorrhea  can  be  easily  evaded  in  the 
majority  of  instances  by  a  clever  prostitute.  The  examination  for 
both  diseases  to  be  even  partially  effective  calls  for  laboratory 
equipment  and  special  skill  not  usually  available,  and  for  time, 
which  officials  making  such  examinations  do  not  have.  The  result 
of  a  negative  examination  on  one  day  may  be  reversed  on  the  next 
by  the  appearance  of  a  flare-up  or  a  contagious  lesion  of  which  the 
patient  herself  may  be  unaware.  It  is  true  that  so  far  as  the  pre- 
vention of  syphilis  particularly  is  concerned,  there  are  measure^ 
which  have  never  been  employed  on  prostitutes  which  may  have 
greater  value  than  those  used  heretofore.  The  question  arises, 
however,  whether  such  measures  can  ever  be  brought  to  a  pitch  of 
efficiency  which  will  make  them  even  medically  speaking  as  effective 
as  a  vigorous  policy  of  suppressing  and  crushing  out  all  prostitution 
wherever  it  can  be  reached. 

Syphilis  in  the  Lax  and  Indiscrete. — Syphilis  in  particular  does* 
not  wait  for  sexual  intercourse  in  order  to  attack  the  lax  and  care- 
less. Those  who  permit  liberties  to  be  taken  with  their  persons  in 
the  form  of  kissing  and  caresses  which  do  not  go  to  the  point  of 
actual  sexual  relations,  are  subject  to  a  risk  of  infection  which  is 
larger  than  is  generally  realized.  This  risk  is  doubled  by  the  mis- 
taken belief  of  both  parties  that  by  indulging  in  mild  offenses  they 
escape  the  dangers  of  an  outright  breach  of  decency. 

Unsocial  Sexual  Relations  Cannot  Be  Made  Safe. — On  the  whole 
it  is  a  conservative  judgment  that  no  device  exists  by  which  unsocial 
sexual  relations  can  be  made  safe  from  the  standpoint  of  genital 
infection.  It  is  difficult  to  believe  that  the  attainment  even  of 
maximum  efficiency  in  their  public  health  control  will  totally  do 
away  with  syphilis  and  gonorrhea.  They  will  remain  the  heritage 
of  lust.  It  is  axiomatic  that  the  quintessence  of  caution,  the  most 
highly  specialized  instinct  of  the  ''knowing  one"  for  the  "safe 
chance"  sooner  or  later  goes  astray.  Where  infection  has  been 
most  carefully  ruled  out,  or  is  least  suspected,  there  it  occurs. 

The  Struggle  Against  Prostitution ;  Regulation,  Repression,  Legal 
Measures. — It  is,  of  course,  impossible  in  a  study  of  this  kind  to  dis- 
cuss at  length  the  methods  of  attack  upon  prostitution  as  the  car- 
rier of  syphilis  and  gonorrhea.  The  older  conception  that  the  sit- 
uation was  hopeless  has  no  foundation  in  fact.  The  control  of  the 
more  intangible  and  clandestine  types  of  unsocial  sexual  relations 


120 

is  a  problem  in  morals,  psychology  and  fidohomics.  The  control  of 
commercialized  vice  which  is  probably  the  larger  factor  of  the  two 
is  a  matter  of  public  administration  and  the  systematic  and  deter- 
mined employment  of  repressive  force.  Regulation  of  prostitution, 
in  effect  an  attempt  to  herd  it  together  and  control  it  by  systems 
of  inspection  and  registration  is  of  long  standing  on  the  Continent, 
and  during  the  war  was  a  part  of  the  accepted  policy  of  certain  of 
the  belligerents.  The  plan  has  innumerable  weaknesses,  apart  from 
its  contemptibility  as  an  expedient.  Policies  of  toleration  and 
regulation  are  giving  way  before  repression  or  abolition,  which  con- 
sists in  the  systematic  stamping  out  of  vice  wherever  it  can  be 
found.  To  the  United  States  belongs  the  distinction  of  demon- 
strating  in  connection  with  the  military  and  naval  policy  of  this  war, 
that  repression  is  not  only  the  only  respectable,  but  by  all  odds  the 
most  highly  eflScient  policy  which  a  community  or  a  nation  can 
adopt.  The  most  effective  implements  in  civil  life  against  com- 
mercialized vice  are  those  which  separate  the  commercial  and  the 
vice  by  attacking  the  former.  As  soon  as  organized  prostitution 
ceases  to  be  a  paying  proposition,  it  begins  to  dwindle  in  influence 
and  extent.  The  removal  of  the  pernicious  influence  of  the  liquor 
traffic  which  reaps  enormous  profits  from  organized  prostitution,  has 
had  remarkable  effect.  A  very  ingenious  and  effective  legal  instru- 
ment exists  for  making  commercialized  prostitution  unprofitable. 
This  is  known  as  the  injunction  and  abatement  law,  and  its  mode  of 
action  consists  in  tying  up  property  both  real  and  personal,  which 
can  be  shown  to  be  used  for  immoral  purposes.  It  is  so  effective 
that  one  vigorous  application  will  put  an  entire  red  light  district  out 
of  business,  and  the  law  can  then  be  employed  in  ferreting  out  and 
crushing  the  sporadic  and  scattered  activities  which  follow  it. 

State  Care  of  Delinquent  Girls. — A  measure  directed  against  pros- 
titution whose  importance  has  repeatedly  impressed  me,  is  the  prop- 
er provision  by  the  state  for  the  care  of  mentally  or  morally  deficient 
girls,  who  through  weakness  and  lack  of  moral  sense  and  backbone 
rather  than  viciousness  are  led  into  prostitute  careers.  Many  such 
patients  are  encountered  in  the  course  of  medical  consultation  work, 
and  the  problem  as  to  what  to  do  with  them  has  had  deplorably 
little  attention.  Industrial  schools  do  them  no  good,  since  the  diffi- 
culty is  inherent  and  cannot  always  be  trained  away.  They  are  not 
insane  or  imbecile,  and  hence  cannot  be  committed  to  the  average 
asylum.  The  influence  of  everyone  interested  in  the  movement 
against  genital  infections  should  be  enlisted  in  trying  to  secure 
farm  colonies  for  these  types,  where  they  can  be  under  custodial 
care  for  life. 


121 

The  Fundamental  Principle. — One  principle  stands  out  sharply 
from  aU  the  rest.  Kegardless  of  whether  the  relations  between  the 
sexes  have  reached  or  will  ever  reach  a  final  adjustment,  it  can  be 
unqualifiedly  said  that  commercialized  prostitution  is  wrong  and 
must  go.  Every  self-respecting  man  or  woman  can  without  a  mo- 
ment's hesitation  cast  his  influence  on  the  side  of  repression. 

Alcoholism  and  the  Acquiring  of  Syphilis  and  Gonorrhea. — Al- 
cohol has  two  important  influences  on  the  spread  of  syphilis  and 
gonorrhea.  It  puts  people  in  a  state  of  mind  to  get  infected,  and 
it  decreases  their  resistance  and  systematically  injures  them  once 
they  are  infected.  Estimates  of  the  proportion  of  men  infected 
while  under  the  influence  of  liquor  vary  from  30  to  80  per  cent 
(Riggs).  The  physiological  action  of  the  drug,  even  when  taken 
short  of  intoxication  is  to  take  off  the  brakes,  remove  the  inhibitions, 
so  that  acts  which  an  individual  could  not  perform  in  a  normal 
state  without  losing  his  self-respect,  become  matters  of  course  under 
alcohol.  Befuddlement  and  confusion  further  add  to  the  effect  by 
making  the  individual  not  only  rash  but  undiscriminating,  so  that 
he  will  assume  risks  which  he  would  have  avoided  if  he  had  been 
in  possession  of  his  faculties.  A  drunken  man  not  only  can  be  be- 
trayed into  any  sort  of  situation,  but  is  powerless  to  take  any  meas- 
ures to  prevent  infection  until  too  late.  That  no  amount  of  cultural 
tradition  avails  against  a  few  drinks  is  abundantly  evidenced  by 
the  downfall  of  many  a  splendid  college  man.  The  influence  of  al- 
cohol upon  girls  and  women  is  no  less  dangerous.  The  wine-list  on 
the  back  of  a  cafe  menu  is  responsible  for  the  tragic  ending  of  many 
a  seemingly  innocent  supper.  If  alcohol  could  be  absolutely  ex- 
cluded from  every  point  of  social  contact  between  men  and  women, 
there  would  be  an  immediate  drop  in  the  incidence  of  syphilis  and 
gonorrhea.  The  influence  of  alcohol  in  promoting  sexual  indiscre- 
tion has  been  exploited  without  scruple  by  the  liquor  interests  of 
the  world,  and  furnishes  alone  an  adequate  reason  for  their  extinc- 
tion. Kneeland's  astonishing  presentation  of  the  relation  between 
commercial  alcohol  and  commercial  vice  is  classical  and  should  be 
read  by  every  adult.  ^ 

Physiologic  Effects  on  Persons  Already  Infected. — The  physiologic 
effect  of  alcohol  upon  the  gonorrheic  has  been  mentioned.  It  makes 
infection  easier,  and  it  promotes  relapse  in  the  acute  stage.  Upon 
the  syphilitic  the  influence  of  the  drug  seems  to  be  mainly  upon  the 
nervous  system.  The  combination  of  alcohol  and  syphilis  tends 
sharply  toward  locomotor  ataxia  and  general  paresis,  and  toward 

1  Kneeland  George  J. :  Commercialized  Prostitution  and  the  Liquor  Traffic.  Social 
Hygiene,  1916,  n,  69-90. 

r.    Clark     Walter    (Field    Secretary    of    the    American    Social    Hygiene    Association): 
Prostitution  and  Alcohol.     Social  llygiene,   1917.  iii,  75-90. 


-J  22 

serious  involvement  of  the  kidneys,  tlie  blood  vessels  and  the  liver. 
A  syphilitic  who  drinks  is  predisposed  to  danger  from  treatment  as 
well  as  disease,  and  on  the  whole  deserves  little  consideration  un- 
less he  stops. 

Other  Phmes  of  Commercial  Exploitation  of  Bex;  the  Stage^^ 
Books,  Clothes,  Etc. — Commercialization  of  the  sex  impulse  extends 
to  other  fields  than  those  of  alcoholism  and  prostitution.  The  filthy 
picture  industry  and  other  grossly  indecent  activities  still  thrive. 
Less  flagrantly  but  still  regrettably,  the  moving  picture  theater,  the 
legitimate  stage,  books,  and  clothes,  all  reflect  the  eagerness  to  coin 
sex  curiosity  and  sex  desire  into  cash.  While  it  is  scarcely  neces- 
sary to  be  Comstockian  in  repression  of  every  aspect  of  the  nude, 
there  can  be  no  escape  from  the  fact  that  the  vogue  of  "leg  shows," 
suggestive  gesture  and  dancing,  risque  plays  and  peek-a-boo  gar- 
ments is  inspired  by  something  more  than  a  return  to  appreciation 
of  the  Grecian  in  art.  It  preceptibly  raises  the  tempo  of  sex  life, 
and  cannot  be  dismissed  as  negligible  by  the  student  of  sexual 
morale.  While  we  need  not  become  fanatics,  it  is  unwise  to  ridicule 
unqualifledly  those  who  speak  on  the  side  of  caution  in  these  things. 
The  trend  is  there,  and  best  recognized  for  good  or  ill,  rather  than 
veiled  under  an  assumed,  because  convenient,  broadmindedness.  If 
eroticism  is  to  be  the  trend  of  the  times,  perhaps  well  and  good. 
It  may  be  that  nature  is  thus  asserting  herself  in  the  struggle 
against  modern  economic  checks  upon  the  sexual  life.  But  profit- 
able eroticism  has  no  excuse  for  being. 

We  return  then  to  the  point  at  which  we  began.  Every  act  and 
every  industry  which  makes  a.  dollar  out  of  the  stimulation  of  sex 
impulses  deserves  the  closest  scrutiny  and  the  most  persistent  super- 
vision from  those  intent  on  sexual  idealism.     It  plays  with  fire. 


123 

CHAPTER  IV. 

MORAL  AND  EDUCATIONAL  PROPHYLAXIS  OF  SYPHILIS 

AND  GONORRHEA.     PROBLEMS  AND  METHODS 

OF  SEX  EDUCATION. 

Morale  and  the  Sexual  Life. — It  has  taken  the  war  to  demon- 
strate the  extraordinary  efficiency  of  morale  in  every  phase  of 
struggle.  In  the  sexual  life  no  less  than  on  the  field  of  battle,  it  is 
paramount.  A  high  morale  has  an  efficiency  as  a  preventative  of 
syphilis  and  gonorrhea  in  comparison  with  which  even  the  triumphs 
of  medical  prophylaxis  take  second  place.  The  conservation  and 
the  development  of  morale  in  the  sexual  life,  therefore,  becomes  not 
a  mere  side-issue,  but  a  first  dut}^  Four  fundamental  factors  con- 
tribute to  a  high  standard  of  sexual  morale.  These  are :  a  positive 
as  distinguished  from  a  merely  negative  or  prohibitive  idealism; 
numerous  effective  and  clean  outlets  for  the  energy  of  the  sex  im- 
pulse and  the  ideals  that  it  underlies;  certain  fundamental  habit 
inhibitions;  the  teaching  of  the  young  child,  not  the  adolescent  or 
the  adult,  the  character  basis  for  a  healthy  sex  life.  , 

Positive  Idealism  and  Idealistic  Expression. — ''li;lan,"  that  vivid 
French  word  to  express  the  ardor  and  exultation  of  battle,  is  a  prod- 
uct of  the  attack,  rather  than  of  defense.  A  man  may  stubbornly  but 
without  enthusiasm,  defend  himself  from  temptation.  But  give  the 
force  behind  the  temptation  something  positive  to  work  for  and  it  is 
transformed  into  inspiration.  For  example  "Thou  shalt  not  covet 
thy  neighbor's  wife,"  and  "thou  shalt  not  commit  adultery,"  have 
force,  to  be  sure,  but  they  lack  as  principles  the  breadth  and  the 
effectiveness  of  the  positive  injunction  which  embraces  all  that 
either  of  them  could  mean  "Thou  shalt  love  thy  neighbor  as  thy- 
self." The  sexual  life  of  humanity  needs  inhibitions  to  be  sure — 
but  too  often  the  negations  have  been  substituted  for  the  outlets 
and  expressions,  and  dwarfing  without  ennoblement  has  been  the  re- 
sult. To  the  efi'ect  of  lifelong  repression  and  inhibition  of  sex  ex- 
pressions and  yearnings  much  of  the  barrenness  of  many  a  withered 
marriage  has  been  due.  It  is  an  essentially  evolutionary  and  stimu- 
lating view  of  the  possibilities  of  the  sexual  life  which  teaches  a 
self-control  that  expresses  itself  in  noble  action  rather  tlian  in  the 
negative  virtue  of  frigid  ultra-restraint.  To  teach  sexual  morale 
as  a  thing  which  can  and  should  be  an  expression  of  one's  best,  not 
an  inhibition  of  one's  worst,  is  to  teach  it  dynamically  and  synthet- 
ically, and  to  enlist  in  the  cause  all  the  upward  tendency  of  the 
race. 

Altruistic  Outlets  for  Scmial  Energy. — If  a  high  sexual  morale 
is  to  be  a  form  of  enlightened  expression  rather  than  suppression  it 


124 

is  necessary  to  plan  altruistic  outlets.  One's  lower  centers  in  a 
state  of  physical  health  take  care  of  our  impulse  to  physical  ex- 
pression. What  the  vast  body  of  men  and  women  need  to  have  in- 
sistently shown  them,  is  the  fact  that  there  are  indirect  expressions 
of  the  sexual  instinct  which  will  enrich  both  themselves  and  the 
world.  Few  passionate  but  controlled  souls  escape  the  learning  of 
this  lesson.  More  could  be  taught  it,  if  there  were  more  teachers 
and  the  teaching  were  begun  earlier.  The  woman  who  in  default  of 
marriage  and  children,  mothers  the  family  of  another;  the  nurse 
whose  care  of  the  sick  has  all  the  tenderness  of  the  love  of  woman 
for  man  and  mother  for  child,  are  examples  of  it.  The  man  who 
builds  into  the  fabric  of  a  great  lifework  the  love  of  the  woman  he 
cannot  have  or  never  met,  is  a  less  familiar  but  no  less  needed 
type.  Gospel  of  this  sort  seems  sometimes  far  removed  from  the 
sordid  details  of  this  or  that  wreck  we  know  of,  and  yet  it  is  funda- 
mental and  vital,  and  analysis  leads  us  to  it  again  and  again.  The 
torrent  of  obscenity  which  belches  from  the  mouth  of  "a  brickyard 
paddy  has  at  least  the  latent  energy  of  sewage.  If  as  a  child  he 
had  been  taught  a  different  mode  of  expression  for  that  same  force, 
he  might  have  been  a  power  for  good  as  a  man.  Outlets,  physical 
and  spiritual,  for  the  energy  of  the  sexual  life,  are  part  of  the  es- 
sential mechanism  for  the  preservation  of  its  morale. 

The  Fundamental  Inhibitions;  Sound  Character  as  a  Basis  of 
Self-Gontrol. — An  unqualifiedly  positive  and  expressive  philosophy 
in  the  sex  life  would  be,  of  course,  overbalanced.  There  must  be 
fundamental  inhibitions.  The  "Everlasting  No"  in  the  sexual  life 
must  be  bred  in  the  bone,  not  merely  put  on  as  a  garment.  It  is 
moreover,  a  habit,  not  an  enlightened  rationalism.  The  man  to 
whom  the  phj^sical  degradation  of  resort  to  a  prostitute  for  sexual 
relief  is  impossible,  is  not  the  product  of  the  logic  of  the  situation, 
ov  its  fears.  He  is  physically  incapable  of  an  act  that  runs  counter 
to  the  instincts  of  cleanliness  bred  in  him  with  tooth-brush  and 
soap,  as  well  as  the  more  spiritual  forms  of  cleanliness  expressed 
in  the  straight-forward  eye  and  the  ring  of  sincerity  and  honesty  in 
the  voice.  The  strongest  safeguard  against  syphilis  and  gonorrhea 
which  a  man  or  woman  can  have  is  not  knowledge  of  risks  of  in- 
fection or  familiarity  with  means  of  avoiding  them,  but  sound  char- 
acter. The  type  of  personality  that  loves  its  neighbor  as  itself, 
that  lives  rather  than  talks  the  square  deal,  that  is  tender,  chiv- 
alrous, loyal,  and  generous,  possesses  a  margin  of  sexual  safety  for 
which  there  is  no  prophylactic  substitute.  Make  a  mati  first;  teach 
Mm  honor,  make  his  word  his  bond,  his  first  thought  for  the  other 
fellow — then  let  him  love,  and  there  will  be  little  cause  for  fear. 


125 

Teach  the  Child. — A  foundation  of  the  type  I  have  described  is 
laid  at  only  one  time  in  life — in  childhood.  If  sexual  morale  de- 
pends on  <!haracter,  it  is  folly  to  try  to  paint  it  on  the  surface  at 
puberty.  Those  who  have  tried  their  hand  at  reconstruction  in 
adults  likewise  appreciate  the  futility  of  trying  to  mold  the  hard- 
ened clay  of  the  sexual  experience  of  later  life.  If  we  are  to  grasp 
the  opportunity  to  create  a  sexual  idealism  we  must  teach  it  to  the 
children.  The  opportunity  often  comes  in  my  experience,  by  utiliz- 
ing those  who  have  suffered  themselves,  and  will  take  the  steps  that 
save  their  children  from  a  similar  fate.  The  mother  who  has  been 
infected,  or  who  has  had  the  opportunity  to  see  at  first  hand  the 
experience  of  another,  makes  an  able  ally.  Projects  for  the  reforma- 
tion of  the  adult  sexual  offenders  of  our  own  generation  require  a 
superlative  and  in  the  end  usually  a  futile  evangelism.  If  we  are 
to  reconstruct,  it  must  be  through  our  children. 

Home,  Protection  and  the  WorTc  Outlet  in  Sex  Education. — Sound 
sex  education  is  a  highly  complex  affair.  It  demands  the  intelligent 
employment  of  recreation,  of  discipline,  of  hard  work,  of  responsi- 
bility, even  of  hardship,  as  means  to  an  end.  The  scene  par  excel- 
lence for  the  play  of  these  forces  upon  the  child  is  home.  No  system 
of  schooling,  no  formal  method  of  training  will  ever  be  an  adequate 
substitute  for  the  right  kind  of  a  family  life.  To  remedy  a  defect 
or  find  a  cause  in  a  sexual  blunder,  go  back  to  the  home  and  the 
family.  The  child  who  is  insolent  and  disobedient,  the  boy  who  is 
unsportsmanlike,  who  has  an  allowance  he  does  not  earn,  the  will- 
ful, pert  girl  with  skirts  too  short  and  hair  too  high,  the  youth 
with  silk  hose,  and  cigarette  hanging  from  the  lips,  owner  of  an 
automobile  when  he  should  be  mastering  the  wheelbarrow,  are  feed* 
ers  of  the  mill  of  sexual  catastrophe.  Unsupervised  companion- 
ships between  boys  and  girls,  idle  evenings,  personal  familiarities 
and  especially  physical  contacts  between  the  sexes,  seem  outwardly 
harmless,  but  they  are  the  starting  points  of  trouble.  It  should 
not  take  a  medical  expert  in  syphilis  and  gonorrhea  to  appreciate 
that  it  is  not  a  cold  old-maidishness  but  simple  common  sense  which 
throws  protection  around  young  girls,  and  keeps  young  fellows 
busy  striving,  studying  and  working  instead  of  philandering.  Pro- 
tection and  the  work  outlet  should  come  into  play  early.  Few 
men  who  can  look  back  with  frankness  upon  their  boyhood  and 
school  days  really  believe  that  sexual  activity  begins  with  puberty, 
or  that  sexual  stimulants  such  as  dancing  and  tete-a-tetes,  can  be 
allowed  full  play  untempered  with  judgment,  if  we  are  really  to  take 
our  sex  standards  seriously. 

Virginity  is  Only  Half  the  Protlem. — The  object  of  a  successful 
teaching  of  sexual  morale  is  not  merely  to  marry  virgin  women  to 


126 

virgin  men.  Pre-marital  continence  in  only  one  phase  of  the  prob 
lem.  Many  a  mother  heaves  a  sigh  of  relief  when  she  has  her 
daughter  safely  married  off,  forgetting  that  there  are  wolves  with- 
in as  well  as  without  the  fold,  though  perhaps  of  a  different  stripe. 
The  man  or  woman  whose  whole  sexual  training  has  been  concen- 
trated on  virginity  and  suppression  can  be  as  hopeless  an  impos- 
sibility in  a  workable  sexual  career  as  a  Light  o'  Love.  To  this  side 
of  the  problem,  by  all  odds  the  more  difficult  of  the  two,  little 
thought  has  been  devoted.  Inhibitions  may  make  the  virgin,  but 
it  takes  dynamic  idealism,  some  power  of  expression,  and  physical 
fitness  to  make  the  successful  father  and  mother,  husband  and 
wife.  To  this  dynamic  idealism  all  the  variegated  experiences  of 
living — those  gained  in  work,  in  recreation,  in  hardship,  and  in 
adversity,  contribute  the  gifts  which  make  achievement.  It  is  our 
double  duty  to  see  that  our  children  do  not  lack  their  share  of  these 
essential  aids. 

Value  of  Sew  Instruction. — Education  in  the  facts  of  the  sexual 
life  is  to  many  the  stone  of  stumbling  in  modern  ideals  for  a  higher 
sexual  morale.  Opinion  on  the  correct  technic  of  such  teaching  is  in 
the  making.  The  actual  value  of  education  in  sex  matters  is,  how- 
ever, fairly  well  settled.  For  example,  Riggs,  at  the  Norfolk  Naval 
Training  Station,  was  able  by  purely  educational  methods,  to  reduce 
the  percentage  of  sexual  exposure  in  a  large  body  of  men,  from  126.7 
per  cent  to  38.6  per  cent  in  a  period  of  tAVO  and  one-half  years. 
Ninety  per  cent  of  676  college  men  in  a  special  survey  estimated 
that  they  had  been  benefited  by  sex  instruction  received  from  whole- 
some sources.  On  the  other  hand,  79  per  cent  of  690  college  men 
who  had  received  their  first  information  from  other  boys  and  girls 
and  miscellaneous  sources,  estimated  the  effect  to  have  been  bad. 
As  between  the  taught  and  the  untaught  the  difference  is  so  striking 
as  to  justify  even  the  timid  in  making  an  effort  to  instruct  those  to 
whom  they  owe  a  duty. 

Methods  and  Technic  of  Sex  Instruction. — Impressions  of  the 
methods  and  technic  of  sex  instruction  may  be  briefly  summarized 
as  folloAvs.  The  age  at  which  children  begin  to  acquire  first  im- 
pressions of  sex  is  much  less  than  is  commonly  supposed,  and  much 
earlier  than  the  age  of  the  official  attempts  to  impart  information. 
The  estimated  age  of  first  sexual  impressions  in  a  large  survey  was 
9.6  years,  the  age  at  which  wholesome  instruction  was  first  received 
15.5  years.  The  sex  education  of  children  as  such  must  therefore 
be  begun  much  earlier  than  puberty,  as  previously  pointed  out.  If 
the  parent  frankly  confronts  the  first  questions  asked  by  the  child 
and  answers  them  simply,  truthfully  and  directly,  mthout  too  much 
detail,  the  simplicity  of  tlie  oliild  nnd  tlio  entire  nbseiioe  of  the  self- 


consciousness  of  puberty  will  make  the  situation  easier  to  manage 
thereafter.  The  child  should  be  repeatedly  impressed  with  the  fact 
that  the  source  of  information  on  such  matters  is  the  father  and 
mother,  not  friends  and  companions,  and  that  the  subject  is  never 
to  be  discussed  outside.  Emphasis  on  the  impersonal  and  larger  as- 
pects of  sex  is  essential.  Children  respond  well,  in  my  experience, 
to  explanations  of  honorable  conduct  toward  each  other.  The  phy- 
sical side  should  be  biologized  at  first  by  the  use  of  plants  and 
other  animals,  but  to  be  effective  it  must  always  come  back  to 
human  beings,  although  an  excessive  literalism  is  to  be  avoided. 
While  corn  and  tiger  lilies  and  other  examples  from  real  life  are 
valuable,  pictures  of  human  anatomy  are  generally  conceded  to  be 
undesirable  because  too*  suggestive.  The  choice  of  words  is  the 
most  embarrassing  problem  to  the  untrained.  It  can  be  overcome 
to  no  small  extent  by  reading  some  of  the  literature  illustrating 
methods  of  approach,  which  is  obtainable  from  accredited  sources  at 
the  present  time.^  During  the  earlier  years  of  a  child's  life  it  should 
be  taught  personal  cleanliness,  learn  not  to  meddle  with  the  geni- 
talia, and  acquire  a  profound  respect  for  these  parts,  which  little 
children  learn  well  on  repeated  insistence.  If  children  are  found 
to  have  made  a  false  start,  it  is  the  height  of  folly  to  resort  to  fear 
or  threats.  Both  of  them  drive  the  child  violently  in  upon  himself, 
and  in  the  case  of  masturbation  especially,  lead  to  mental  states  in- 
finitely worse  than  the  original  trouble.  In  the  earlier  years  is  laid 
the  whole  foundation  of  the  intimate  friendliness  between  parent 
and  child  which  will  draw  the  two  together  and  make  the  child  ap- 
proachable during  the  transitions  and  self -consciousness  of  puberty. 
The  parent  must  play  an  active  part  and  move  toward  the  child,  not 
wait  for  the  latter  to  approach  him.  It  is  surprising  how  easily 
satisfied  a  child's  curiosity  is,  and  how  often  vicious  information 
comes  to  him  gratuitously,  and  not  of  his  own  seeking. 

Companions  and  Books. — The  companionships  of  a  child  must  be 
closely  watched,  and  this  not  by  watching  the  companion  alone, 
but  by  watching  his  parents,  and  estimating  the  type  and  degree  of 
Iheir  influence.  A  boy  whose  father  and  mother  let  him  grow  up  as 
a  weed  has  a  surprising  capacity  for  imparting  weedy  characteristics 
to  the  better  stock  of  the  neighborhood.  Older  boys  are  a  particular 
danger,  and  unsupervised  walks  and  absences  with  older  boys  are 
often  fully  as  dangerous  to  sexual  integrity  as  later  un  chaperoned 
contact  between  the  two  sexes.  A  boy's  first  lessons  in.  his  relation 
to  girls  should  take  the  form  of  chivalric  regard  for  mother  and 

'A  written  request  for  booklets  or  teaching  material,  addressed  to  the  United 
States  Public  Health  Service,  228  First  Street,  N.  W..  Washington,  D.  C  with  a  state- 
ment of  the  age,  sex  and  social  status  of  the  persons  concerned,  will  receive  a  prompt 
response. 


128 

sister,  and  the  cultivation  of  his  protective  instinct  for  them.  To 
make  it  part  and  parcel  of  a  boy's  creed  that  he  who  harms  a 
woman  is  a  cad  and  a  bum  sport  as  well  as  a  coward  is  to  build 
up  insurance  for  clean  living.  Books,  too,  have  no  small  influence 
on  adolescent  sex  ideals.  A  course  of  the  sentimentalistic  mush  too 
easily  available  to  unguided  boys  and  girls  has  paved  the  way  to 
many  a  premature  emotional  crisis  and  sexual  disaster. 

Good  Sportsmanship  and  Hardy  Living. — Woodsmanship,  as 
among  the  Boy  Scouts,  vigorous  exercise,  forms  of  activity  involv- 
ing team  play,  teach  fundamental  ideals  of  sportsmanship  and  the 
square  deal,  and  have  a  vital  place.  The  leaders  in  these  movements 
should  be  selected  with  the  utmost  care,  on  a  basis  of  personal  char- 
acter and  not  on  that  of  mere  craftsmanship.  The  foulest  mouth 
and  the  vilest  personality  I  have  ever  met  in  a  variegated  experience 
was  that  of  the  much  prized  captain,  athletic  idol  and  all- American 
star  of  the  football  team  of  a  great  university.  Athletics  for  its 
own  sake  breeds  dangerous  types  of  personality.  The  so-called  ama- 
teur ideal  of  training  to  a  pitch  whose  height  only  serves  to  empha- 
size the  fall  when  training  breaks,  has  no  place  in  the  kind  of 
sportsmanship  that  develops  sexual  morale. 

The  Time  -for  Plain  Facts. — Syphilis  and  gonorrhea  should  not  be 
mentioned  to  children.  It  is  my  personal  belief  that  the  essential 
facts  of  the  carrying  of  sperm  to  egg  cell  in  the  human  being,  told 
in  purely  impersonal  language  and  devoid  of  detail  can  be  given 
to  both  boys  and  girls  just  before  puberty.  Information  of  this 
sort  to  be  protective  must  not,  however,  be  too  vague.  Girls  for 
example,  can  be  warned  to  make  boys  keep  "han^s  off"  and  boys 
similarly,  enjoined  against  caressing  and  handling  girls.  The 
pubescent  boy  or  girl  can  then  be  told  if  the  situation  seems  threat- 
ening, about  the  genital  infections.  Much  depends  on  the  indi- 
vidual. In  general  such  knowledge  comes  best,  I  believe,  between 
the  fifteenth  and  the  eighteenth  year.  While  sexual  experience  occa- 
sionally occurs  soon  after  the  twelfth  year,  a  sound  foundation  in 
character  and  elementary  training  will  make  any  restraining  in- 
fluence that  fear  can  lend  unnecessary  until  maturity  is  well  estab- 
lished. The  importance  of  seeing  that  every  girl  at  this  time  under- 
stands the  physiology  of  menstruation  and  every  boy  understands 
the  seminal  emission  and  is  put  on  his  guard  against  quacks,  cannot 
be  overemphasized. 

Visual,  Graphic  and  Personal  Teaching;  the  Speaker. — War  ex- 
perience has  definitely  demonstrated  the  superiority  of  \isual, 
graphic  and  personal  methods  of  teaching  over  books,  leaflets  and 
other  forms  of  printed  matter.  None  the  less  the  latter  must  be 
resorted  to  and  have  an   important  place.    Visual   methods  call 


129 

for  discretion.  Skilfully  prepared  exhibits  of  the  poster  type  are 
effective^  especially  when  accompanied  by  facilities  for  free  private 
medical  advice — a  fact  which  quacks  have  long  used  as  a  drawing 
card.  Bulk  methods  of  verbal  teaching  of  sexual  facts  to  younger 
people  are  to  be  discountenanced.  Very  few  speakers  have  shown 
themselves  able  to  handle  them.  Hunger,  in  the  Navy,  had  oppor- 
tunity to  observe  its  undesirability  and  relative  ineffectiveness. 
It  is  impossible  to  strike  a  tone  that  fits  all  ages  or  types  even  in 
a  one-sex  audience  under  eighteen  years  of  age.  It  is  vital  in  these 
matters  that  the  speaker  be  en  rapport^  and  a  giggle  is  enough  often 
to  mar  the  situation.  Amateurs  should  not  practice  upon  au- 
diences. Before  older  groups  a  forceful  and  well-informed  speaker 
can  dominate  the  situation.  The  presentation  of  sex  material  in 
lectures  is  an  art  in  which  many  are  called  but  few  chosen.  The 
most  powerful  and  effective  speakers  I  have  heard  have  combined 
a  commanding  personality  with  the  ability  to  express  themselves 
in  the  vernacular.  In  other  words,  they  have  possessed  the  quali- 
ties of  popular  leadership.  The  fault  of  many  lecturers  is  their 
tendency  to  talk  from  above  down,  to  be  too  vague  and  to  indulge  in 
pendantry,  bathos,  or  sesquipedalian  verbiage.  It  is  possible  to  give 
an  unforgettable  talk  on  sex  ideals  without  direct  reference  to  the 
Deity,  or  to  vice  and  sin.  There  is  that  in  clean  living,  good  sports- 
manship and  the  square  deal  for  women,  that  instinctively  appeals 
to  red-blooded  men,  and  its  application  to  the  sexual  life  is  more 
often  obscured  than  furthered  by  turgid  rhetoric. 

1  Osborne,  P.  J. :  A  health  exhibit  for  men.  An  educational  exhibit  on  venereal 
disease  control  and  prevention  presented  at  Coney  Island  by  the  New  York  Social 
Hyg-iene   Society,   Social   Hygiene,  1916-17,   iii,  27-49. 


130 

CHAPTER  V. 

THE  PUBLIC  HEALTH  CONTROL  AND  PERSONAL  PROPHYLAXIS 
OF  SYPHILIS  AND  GONORRHEA. 

The  Public  Health  Control  of  Syphilis  and  Gonorrhea. — Public 
health  control  of  the  genital  infections  is  meant  to  include  those  ele- 
ments which  organized  public  health  work  contributes  directly  to 
the  campaign  against  these  diseases.  As  legitimate  parts  of  public 
health  activity  we  must  rate  the  systematic  suppression  of  tempta- 
tion to  indecency  involved  in  the  abolition  of  prostitution,  and  the 
extinction  of  the  liquor  traffic.  No  attempt  to  control  syphilis  and 
gonorrhea  deserves  serious  consideration  until  it  has  a  thoroughly 
organized  and  uncompromising  policy  with  reference  to  these  two 
factors.  The  gross  stimulation  of  sexual  impulses  must  go.  This 
and  other  essentials  of  a  public  health  campaign  against  syphilis 
and  gonorrhea  are  admirably  illustrated  in  the  policy  of  the  United 
States  Government  as  outlined  by  Major  Sawyer,  and  need  not  be 
duplicated  here. 

The  Church  and  the  Problem. — Attention  has  already  been  called 
to  a  point  of  contact  between  the  church  and  the  problem,  which 
deserves  re-emphasizing;  that  is,  the  influence  of  the  former  over 
the  solemnization  of  marriage.  Few  obligations  seem  more  obvious 
than  that  the  institution  which  stands  determinedly  for  the  inviola- 
bility of  this  moral  and  social  bond  should  feel  a  direct  sense  of  ob- 
ligation in  determining  the  fitness  of  those  who  enter  into  it.  The 
clergjonan  and  the  priest  are  exercising  their  highest  function  in 
company  with  the  physician  and  the  parent  when  they  feel  toward 
the  marriages  of  their  parishioners  a  sense  of  responsibility  greater 
than  that  attached  to  any  other  duty  which  they  may  perform.  If 
they  feel  that  sense  of  responsibility,  the  marrying  parson  and  the 
ecclesiastical  marriage  mill  will  cease  to  exist.  A  closer  guardian- 
ship of  the  entrance  into  marriage  will  obviate  the  necessity  for  so 
much  emphasis  on  divorce,  inasmuch  as  the  permanence  of  the 
bond  is  directly  proportional  not  to  penalties  placed  on  its  viola- 
tion, but  to  the  wisdom  that  presided  when  it  was  entered  into. 

The  Neiv  Responsibilities  of  the  Medical  Profession. — The  awaken- 
ing with  respect  to  syphilis  and  gonorrhea  will  place  new  responsi- 
bilities upon  the  medical  profession,  to  which  attention  has  been 
directed  from  time  to  time  in  this  study. 

The  existing  situation  is  not  satisfactory.  It  is  unsatisfactory, 
not  because  the  physician  does  not  feel  the  need  for  better  things 
and  does  not  seek  them,  but  because  better  tilings  have  not  been 
available.  To  know  syphilis  and  gonorrhea  one  must  be  taught,  and 
taught  not  by  men  to  whom  the  subject  is  incideiitnl  dnidgery.  but 


131 

by  enthusiasts.  Such  men  have  formed  no  part  of  the  staff  of  the 
medical  schools  of  the  past.  Even  today  the  number  of  schools 
which  are  teaching  syphilis  and  gonorrhea  with  the  energy  that 
their  place  in  medicine  and  public  health  deserves,  can  be  numbered 
on  the  fingers  of  one  hand.  An  unfortunately  large  proportion  of 
the  medical  profession  are  thus  attempting  to  work  with  a  modern 
situation  using  tools  that  compare  in  effectiveness  with  the  stone 
hammers  and  knives  of  paleolithic  man.  Gonorrhea  lags  in  the 
background  not  alone  because  of  its  inherent  peculiarities  as  a  dis- 
ease, but  because  a  combination  of  adverse  circumstances  has  kept 
enthusiasm  about  it  at  a  low  ebb,  and  teachers  and  fighters  cor- 
respondingly scarce  and  ill-trained. 

Hospitals  and  the  Prohlem. — Conspicuous  examples  of  medical 
Philistinism  of  the  type  that  obstructs  progress  in  this  field  can  be 
found  in  the  attitude  taken  toward  syphilis  and  gonorrhea  by  hos' 
pitals.  While  syphilis  is  not  a  quarantinable  disease  throughout 
its  whole  course,  a  person  with  active  contagious  syphilis  has  no 
business  at  large  in  the  community  until  he  is  temporarily  sterilized 
by  arsphenamine.  A  very  brief  stay  in  hospital  provides  the  needed 
opportunity.  Manj'  of  the  complications  of  gonorrhea  respond 
rapidly  to  bed  treatment,  with  the  avoidance  of  chronicity  and  pro- 
longed contagiousness.  Many  other  reasons  exist  why  there  should 
be  regular  provision  in  general  hospitals  for  the  care  of  patients 
with  syphilis  and  gonorrhea.  Estimates  based  on  large  experience 
call  for  one  hospital  bed  for  these  diseases  to  each  2,000  population 
in  order  to  provide  for  their  modern  treatment.  The  actual  state 
of  affairs  in  our  large  cities  comes  nearer  one  bed  to  10,000  popu- 
lation. The  explanation  appears  to  lie  simply  in  the  medieval  atti- 
tude of  boards  of  trustees  and  hospital  administrators  toward  the 
diseases,  plus  the  belief  that  in  the  existing  state  of  public  senti- 
ment their  proper  care  is  "not  feasible."  That  it  is  eminently 
feasible,  is  demonstrated  by  the  fact  that  probably  the  best-consid- 
ered and  yet  most  conservative  modern  program  against  syphilis 
and  gonorrhea  in  the  world,  that  of  the  Sydenham  Commission  in 
Great  Britain,  embodies  it  and  is  putting  it  into  practice.  In  this 
country  a  mere  half-dozen  or  so  of  hospitals  and  clinics  have  recog- 
nized the  place  of  this  work  in  the  future  of  medicine  and  are  oper- 
ating complete  hospital  and  dispensary  services  under  the  direction 
of  experts.  Two  details  it  is  important  to  remember.  In  the  first 
place  special  venereal  hospitals  treating  syphilis  and  gonorrhea 
alone  are  not  effective  in  meeting  the  general  problems,  because 
patients,  sharing  the  public  prejudice,  feel  themselves  disgraced  by 
resorting  to  a  place  the  mere  attendance  upon  which  constitutes  a 
label.    In  the  second  place  the  need  for  hospital  care  for  the  victims 


132 

of  the  genital  infections  is  not  limited  to  the  down-and-outs  who  are 
ROW  the  best  provided  for.  It  would  be  difficult  to  find  a  hospital  of 
any  size  so  discriminating  in  its  patronage  that  it  has  no  need  for 
beds  to  treat  syphilis  and  gonorrhea.  There  is  no  city  of  25,000  or 
over  whose  hospital  would  not  be  performing  a  public  service  of  the 
first  magnitude  by  taking  the  lead  in  the  development  of  modern 
facilities  for  the  care  of  genital  infections.  Public  demand  for  such 
facilities  combined  with  the  demonstration  that  it  is  not  only  a 
duty,  but  profitable  to  furnish  them,  will  in  the  end  convert  the 
obstructionists. 

The  Press  and  the  ProMem. — The  problem  of  how  to  bring  au- 
thentic, effective  and  yet  properly  guarded  information  on  the  geni- 
tal infections  to  public  attention  through  the  medium  of  news- 
papers, magazines  and  other  influential  organs  of  public  opinion  is 
an  important  one.  Such  a  means  of  making  even  a  few  truth-telling 
words  and  names  common  knowledge,  is  of  the  greatest  service.  To 
be  effective  I  believe  the  following  principles  should  be  followed. 
First,  the  information  must  have  the  sanction  of  a  central  authori- 
tative source,  which  can  standardize  it  and  give  it  a  positive  qual- 
ity. All  through  the  medical  field  of  the  genital  infections  there 
are  seeming  contradictions  and  variations  in  method  and  opinion 
which  are  extremely  confusing  to  the  uninitiated.  When  doctors  dis- 
agree, the  unfortunate  layman,  lacking  the  power  to  interpret,  is 
thrown  into  perplexities  which  leave  him  in  doubt  as  to  whether 
there  is  such  a  thing  as  real  knowledge  on  the  subject.  The  point 
over  which  the  disagreement  occurs  may  be  trivial,  and  the  wrangle 
purely  scholastic,  but  it  breaks  down  the  confidence  in  leadership 
which  promotes  effective  public  action.  Other  obvious  requirements 
of  a  written  propaganda  are  the  judicious  but  not  vulgar  use  of 
the  vernacular,  precisely  as  in  lectures,  and  the  avoidance  of  techni- 
caKty.  Written  material  on  health  matters  should  not  attempt  to 
deal  with  treatment  except  to  outline  general  principles  and  mini- 
mum requirements.  If  it  does  more  than  this,  it  belongs  on  the 
same  plane  as  the  practice  of  medicine  by  correspondence,  which 
can  become  an  insidious  and  vicious  form  of  quackery  to  which  the 
columns  of  many  newspapers  subscribe  even  while  they  ostensibly 
exclude  untrustworthy  and  disreputable  medical  advertising. 
Printed  propaganda  must  steer  between  the  tendency  to  over-emo- 
tionalism that  paints  up  genital  infections  and  hangs  them  in  a 
•  verbal  gallery  of  horrors,  and  the  dry-as-dust  presentation  of  medi- 
cal facts.  It  should  never  be  forgotten,  that  in  print  there  is  no 
human  voice,  no  compelling  eye,  no  sharp  incisive  gesture  that 
drives  a  point  home  to  an  intent  audience.  The  vivid  and  dramatic 
in  life,  unskillfully  managed,  too  often  sounds  like  "sob-stuff"  on 


133 

paper,  and  a  tension  and  tone  that  can  be  safely  carried,  man  to 
man,  fails  of  effect  when  mixed  with  ink.  I  think  too  that  writing 
on  medical  subjects  is  a  form  of  special  pleading  which  should  so 
far  as  possible  be  directed  at  a  specific  audience.  The  effort  to 
make  material  of  this  kind  into  a  single-standard  literary  pabulum 
that  all  who  run  may  read,  makes  it  effective  only  for  the  middle 
third  of  the  world  audience,  affronts  the  intelligence  of  the  upper 
portions  and  flies  over  the  heads  of  the  lower  portions.  Italicizing 
and  scare-head  typography,  too,  while  they  may,  like  the^  loudly 
printed  handbills,  draw  a  crowd,  detract  in  the  end  from  the  force  of 
the  presentation  by  robbing  it  of  dignity.  Where  force  of  this  sort 
must  be  evoked  it  should  be  exerted  personally  and  not  in  print. 
I  believe,  too,  that  convincing  material  for  a  medical  propaganda 
can  best  be  written  by  those  whose  special  experience  and  enthusi- 
asm make  their  thumb-nail  graphic  touches  true  to  life.  Much  of 
the  literature  on  sex  questions  is  flabby.  It  seems  to  lack  genuine- 
ness because  it  is  abstract.  It  is  the  specific  instance,  told  with 
the  art  of  the  raconteur,  and  a  proper  touch  on  lights  and  shadows, 
that  etches  in  the  image  which  inspires  action. 

Laws  and  Law  Enforcement;  Compulsory  Treatment. — It  is  worth 
while  to  say  a  word  or  two  on  the  need  for  new  laws  and  law  en- 
forcement in  the  modern  campaign  against  syphilis  and  gonorrhea, 
since  the  influence  of  intelligent  men  and  women  can  go  far  toward 
shaping  such  legislation,  and  the  creating  of  the  sentiment  which 
sustains  it.  The  rapid  progress  made  during  the  war  has  brought 
certain  issues  into  the  realm  of  certainties  which  would  have  re- 
mained only  possibilities  for  many  years  in  times  of  peace.  To  have 
syphilis  or  gonorrhea,  has  suddenly  ceased  to  be  a  private  affair,  and 
has  become  one  of  public  concern.  The  first  evidences  of  this  change 
of  viewpoint  is  found  in  the  fact  that  syphilis  and  gonorrhea  are 
becoming  reportable  diseases,  like  measles  or  scarlet  fever.  The  sec- 
ond evidence  is  that  it  is  no  longer  a  matter  of  individual  option 
with  the  patient  whether  he  will  be  treated  or  not.  He  must  be 
treated,  and  he  must  be  treated  not  only  until  he  is  not  contagious, 
but  until  he  is  cured.  The  entry  of  this  compulsory  element  into 
the  management  of  syphilis  and  gonorrhea  will  be  welcomed  by  every 
physician  who  has  had  special  experience  with  these  diseases  and 
has  the  interests  of  the  public  at  heart.  The  constant  menace  of 
irresponsibility  can  scarcely  be  appreciated  by  those  who  have  not 
had  to  deal  with  it  under  the  conditions  of  special  and  dispensary 
practice.  The  ignorantly  and  the  willfully  irresponsible  form  a 
large  factor  in  the  spread  of  both  syphilis  and  gonorrhea.  No 
amount  of  personal  good  will  on  the  part  of  the  physician,  no 
amount  of  free  and  available  treatment,  suffices  to  secure  the  co- 


134 

operation  of  some  types.  Perfectly  possessed  of  all  their  faculties, 
they  will  lea\  e  the  consulting  room  with  fervid  assurance  of  good 
intention,  to  disappear  as  completely  as  if  they  had  stepped  off 
the  horizon.  Among  the  ignorant  and  foreigners  the  problem  be- 
comes acute.  I  have  seen  nurse,  interpreter  and  doctor  working  to 
pursuade  a  man  with  a  mouth  and  throat  full  of  syphilitic  germs, 
talking  in  relays,  gesticulating,  arguing,  their  faces  running  the 
gamut  of  emotions  from  good  will  to  the  hopeless  anger  of  defeat, 
cind  seen  the  irresponsible  and  unprincipled  carrier  of  the  disease 
close  the  conversation  by  turning  on  his  heel  and  sauntering  from 
the  room  without  a  word.  The  power  to  press  a  button  and  have 
that  man  arrested  at  the  door  would  have  seemed  God-given  at  that 
moment.  There  is  as  great  a  need  for  legal  compulsion  back  of  the 
control  of  syphilis  and  gonorrhea,  as  there  is  behind  the  prevention 
of  crime. 

The  Reporting  of  Syphilis  and  Gonorrhea  to  Health  Officers. — The 
reporting  of  cases  of  syphilis  and  gonorrhea  to  the  public  health 
authorities  is  at  present -carried  out  in  modified  form  in  a  number 
of  states  in  this  country.  The  measure  is  a  rational  one,  contribut- 
ing information  of  some  value  and  at  the  same  time  doing  much  to 
educate  patient  and  public  in  the  contagiousness  of  the  infections 
concerned.  As  a  means  of  controlling  irresponsibles  it  is  absolute- 
ly essential.  Systems  of  the  type  of  the  AVest  Australian,  do  not 
require  reporting  by  name  unless  the  patient  shows  himself  dis- 
posed to  neglect  treatment  and  thus  subject  other  to  risk.  An  un- 
accountable prejudice  even  against  this  form  of  impersonal  report- 
ing exists  although  it  must  be  admitted  that  the  opposition  too 
often  comes  from  the  type  of  medical  man  whose  methods  and  ideals 
are  a  generation  old,  who  cannot  give  arsphenamine  and  therefore 
does  not  believe  in  it,  and  who  feels  that  a  contagious  disease  is  the 
private  property  of  the  owner  and  may  be  obtained  from  him  on  the 
ancient  principle  of  caveat  emptor.  A  public  which  is  concerned 
for  its  own  protection  will  first  see  that  every  infected  person  who 
is  so  disposed  will  be  able  to  secure  the  best  modern  treatment  with- 
out regard  to  his  means  or  lack  of  them.  Having  fulfilled  its  duty 
in  this  regard,  it  will  be  justified  in  demanding  that  all  infected 
persons,  regardless  of  personal  vagaries  and  desires,  shall  be  treated, 
and  that  if  they  show  themselves  inconsiderate  of  the  welfare  of 
others,  they  shall  feel  the  force  of  the  law. 

Legislation  Needed  on  Medical  Professional  Confidence. — A  neces- 
sary corrolary  to  all  progressive  legislation  on  such  matters  is  a 
provision  which  unbinds  the  tongue  of  tlie  physician^  where  infec- 


"  As  in  the  State  of  Ohio. 


135 

tion  is  about  to  be  transmitted,  aud  even  punishes  him  as  an  ac- 
cessory to  a  crime  if  he  fails  to  do  his  duty  in  making  the  facts 
known  to  the  proper  persons. 

Personal  Prophylaxis;  Continence. — The  so-called  personal  pro- 
phylaxis of  genital  infections  is  the  final  consideration  in  a  dis- 
cussion of  the  prevention  of  these  diseases.  Personal  prophylaxis 
includes  those  things  which  the  individual  can  himself  do  to  avoid 
acquiring  gonorrhea  or  syphilis.  The  standard  of  personal  prophy- 
laxis is  abstinence  from  sexual  relations  and  personal  intimacies 
except  in  normal  marriage  ivith  a  healthy  person.  It  has  no  sub- 
stitutes, and  no  competitors. 

The  Medical  Prevention  of  Syphilis  and  Gonorrhea  .—The  medical 
prophylaxis  of  the  "genital  infections  rests  upon  a  discovery  by 
Metchnikoff,  Koux  and  Maisonneuve  in  1906,  that  a  properly  pre- 
pared medicinal  ointment  containing  certain  mercurial  salts,  if 
rubbed  into  the  place  where  the  germs  of  syphilis  had  been  deposited, 
within  a  few  hours  after  exposure,  was  able  to  prevent  the  develop- 
ment of  a  chancre  by  killing  them  before  they  could  gain  a  foothold. 
This  method  has  been  found  to  have  a  certain  amount  of  efficiency  in 
the  prevention  of  gonorrhea  also,  but  it  has  been  discarded  for  this 
purpose  in  favor  of  the  use  of  certain  injections  into  the  urethral 
canal.  The  combined  prophylaxis  of  syphilis  and  gonorrhea  was 
rapidly  adopted  into  all  the  armies  of  the  world  following  a  series 
of  rigorous  tests,  and  has  demonstrated  a  remarkable  degree  of 
efficiency,  which  has  been  increased  by  the  realization  that  to  be  of 
the  greatest  service  it  must  be  administered  within  an  hour  after 
exposure,  and  be  given  by  a  specially  trained  attendant  under  medi- 
cal supervision.  Medical  prophylaxis  is  not  infallible.  Even  when 
rigorously  carried  out  it  offers  no  protection  against  the  grave 
risks  of  extra-genital  infection.  Its  percentage  of  failure  is  high- 
est precisely  where  the  risk  of  infection  is  greatest,  among  those 
who  cannot  exercise  intelligence  in  its  application.  Then,  too,  ap- 
parently trifling  variations  upon  the  standard  methods  often  render 
it  ineffective,  a  fact  which  accords  with  the  familiar  experience  of 
physicians  as  to  the  uselessness  of  the  average  attempt  of  a  knowing 
patient  to  avoid  infection  by  washes  and  similar  applications.  The 
prophylaxis  of  syphilis  and  gonorrhea  will  to  some  extent  become 
common  knowledge  as  a  result  of  the  wholesale  spread  of  such  in- 
formation through  army  service.  This  does  not  alter  the  fact  that 
to  be  at  its  best  it  must  remain  under  the  control  of  the  medical 
profession.  If  every  person  who  has  been  exposed  to  the  risk  of 
syphilis  or  gonorrhea  could  be  persuaded  to  report  AAdthin  an  hour 
to  a  competent  physician  to  receive  effective  prophylactic  treatment, 
+he  prevalence  of  the  disease  concerned  would  be  enormously  re- 


cluced.  It  remains  for  the  individual  physician  to  adopt  the  standard 
of  personal  relation  to  the  problem  of  prevention  so  ably  set  forth 
in  the  ManuaP  used  by  the  United  States  Army  Medical  Corps. 
As  an  opportunity  to  give  a  few  words  of  sound  advice,  to  encourage 
a  new  clean  point  of  view,  to  bring  home  a  great  moral  principle, 
the  moment  when  a  young  man  appeals  for  rescue  from  the  possibly 
disastrous  results  of  an  indiscretion  has  few  equals  in  the  practice 
of  medicine. 

Conclusion. — This  chapter  closes  the  study  of  the  modern  problem 
of  syphilis  and  gonorrhea.  It  has  been  the  aim  of  the  discussion 
to  present  the  facts  bearing  on  these  diseases  not  alone  as  a  medical 
issue  for  medical  men,  but  as  a  problem  in  human  nature  and  in 
the  moral  strength  and  weakness  of  the  social  .order,  in  whose  solu- 
tion each  and  every  one  of  us  has  his  part.  Though  we  may  be 
spared  the  actual  miseries  of  the  sick,  their  pain  must  now  be 
our  pain,  their  struggle  our  struggle.  Their  defeat  and  death  are 
symbols  of  our  own  futility.  Only  by  such  a  socialization  of  our 
point  of  view  toward  the  public  health  can  we  hope  to  advance  be- 
yond our  present  outlook  and  effectiveness.  With  the  movement 
against  germs  and  bodily  disease  must  go  a  will  to  right  spiritual 
wrong,  an  idealism  for  the  body  which  is  incomplete  without  the 
perfection  of  the  soul.  If  we  see  the  two  as  one,  we  have  made  the 
first  step.  If  we  as  a  race  can  feel  our  brothers'  sickness  as  our 
own,  their  lacks  our  lacks,  tfieir  triumph  in  flesh  and.  spirit,^  our 
triumph,  there  is  in  us  the  stuff  of  destiny  and  there  awaits  us  a 
future  without  finite  limit. 


^  A  manual  of  treatment  of  venereal  disease.  Chicago,  Am.  Med.  Assn.,  1917,  100  pp. 
This  manual  revised  for  use  of  civilian  physicians  and  issued  by  the  United  States 
Public  Health  Sei-vice,  1919. 


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